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ORAL PAPER PRESENTATIONS
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Friday, November 15, 2013  •  10:40 AM – 12:40 PM

and Dlin/Fischer Award
for the best paper submitted for presentation at the Annual Meeting
Saturday, November 16, 2013  •  9:30 – 10:30 AM

Session A: Common Clinical Situations
  B: Delirium
  C: Neuropsychiatry
  D: Physical Symptoms & Health
  E: Psycho-Oncology
  F: Systems-Based Practice
  G: Transplant
  H: Webb Fellows
  [T] = Trainee Paper

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Dlin/Fischer Award
for the best paper submitted for presentation at the Annual Meeting

 

Multiple Medically Unexplained Symptoms and Somatoform Disorders Vastly Increase Sick Leave and Work Disability in Primary Care Patients: A Ten-Year Follow-up Study
Presenting Author:  Per Fink, PhD, DMSc, FAPM
Co-Authors:  Morten Fenger-Grøn, Eva Ørnbøl, Mette Rask, Marianne Rosendahl, Flemming Bro

Purpose: To assess the ten-year outcome as to sick leave and work disability for primary care patients with somatoform disorders (SD) and patients with "multiple symptoms," i.e., mild-to-moderate conditions of medically unexplained symptoms (MUS) not meeting criteria for an SD, compared to patients with a well-defined physical disease .

Methods: 1785 consecutive patients consulting their family physician (FP) were screened by questionnaires for symptoms and mental illness. FPs rated patients' main reason for consultation. A stratified subsample of 701 patients was examined with a standardized diagnostic interview. Diagnostic groups of "multiple symptoms" (n=84) , DSM-IV somatoform disorders (SD) (n=183) and a reference group with well-defined physical disease according to FPs (n=833) were generated. National Danish Register data on temporary (sick leave and vocational rehabilitation) and permanent (full and partial disability pension) health-related benefits were obtained.

Results: At index consultation and at 10-year follow-up, permanent health-related benefits were received by 8.3% (n=7) and 16.7% (n=14) in the "multiple symptoms" group, 19.1% (n=35) and 23.5% (n=43) in the SD group, and 3.5% (n=29) and 6.0% (n=50) in the reference group, respectively. Both the "multiple symptoms" group (HR (Hazard Rate) =2.28, 95%CI: 1.14;4.55) and the SD group (HR=3.26, 95%CI:1.93;5.51) had increased risk of new awards of disability pensions during the 10-year follow-up period, while only the SD group had higher risk of temporary health-related benefits. Differences between groups were statistically significant despite only before adjustment for covariates between patients with "multiple symptoms" and SD. Data on DSM-V symptom disorder and ICD-10 bodily distress disorder criteria have not been analyzed yet but may be presented if diagnostic criteria are released.

Conclusions: This long-term follow-up study of a huge number of primary care patients with SD showed that the disorder has severe long-term consequences for the patients with poor physical and mental health and very high risk of permanent work disability. Furthermore, the sub-threshold group of patients with "multiple symptoms" also had a worse outcome than the reference group. The category of "multiple symptoms" may be a useful tool for early recognition of MUS in primary care who do not meet the criteria for somatoform disorders and thus for the prevention of persistent disorders and disability.

Objectives:

  1. Patients with somatoform disorders are at high risk of work and social disability'
  2. Early or sub-threshold cases can be identified in primary care and are also associated with impairment and work disability.
  3. Recognition, prevention, and treatment are of paramount importance in reducing personal suffering and cost of the condition.

Relevance:
The longest follow-up ever of a huge group of well diagnosed patients with SD. The patients are followed in national Danish registers covering the entire population, including health-related benefits.

 

Session A:  Common Clinical Situations
Moderator:  J. Michael Bostwick, MD, FAPM

[T] Capacity Evaluations & Pregnancy: A Case Series and Review of the Literature
Presenting Author:  Laura McLafferty, MD
Co-Authors:  Priya Gopalan, Jody Glance

Purpose: Assessments of capacity in the general medical setting are nuanced and detailed, requiring psychiatrists to consider several variables, ranging from the core principles of biomedical ethics to patients’ cognitive abilities, as well as third parties who may be affected by a patient’s capacity to make medical decisions. These factors become more complicated when assessing capacity in pregnant patients, as any decision-making affecting the mother also affects the neonate, a third party who cannot speak for him- or herself. We will outline three cases of capacity evaluations conducted in patients during the late stages of pregnancy.

Case Description: We present a series of three pregnant patients seen in a tertiary care women’s hospital for whom psychiatry was consulted urgently for evaluation of capacity to either refuse or consent to delivery. The first patient was acutely intoxicated with opioids and refusing emergent delivery via C-section at 34 weeks gestational age. The second patient requested delivery that was not considered medically necessary at 29 weeks gestational age due to numerous medical complications that the patient felt were affecting her health and that of her unborn child. For the third patient the question of capacity to consent to emergent delivery via C-section was raised at 33 weeks gestational age due to concern for preexisting cognitive deficits. We will discuss the clinical presentation of each case, including reasons why the patient was initially suspected to lack capacity and relevant ethical principles that were considered.

Discussion: Questions of medical decision-making capacity during pregnancy require the consulting psychiatrist to conduct an evaluation that is often complicated and has little legal precedent and limited guidance from studies. We will provide an overview of the core principles of biomedical ethics (respect for autonomy, beneficence, nonmaleficence, and justice) as they apply to circumstances involving pregnancy. Additionally, we will discuss the often emergent nature of childbirth and implication of route of delivery as it relates to the assessment of capacity in the patients in our series. We will include a discussion of clinical factors which may affect capacity assessments during pregnancy, including substance intoxication and withdrawal states, severe chronic mental illness and cognitive deficits, and severe physical disease, such as preeclampsia and diabetes, which may affect morbidity and mortality for both mother and neonate.

Reference:
Kontos K, Freudenreich O, Querques J. Beyond capacity: Identifying ethical dilemmas underlying capacity evaluation requests. Psychosomatics 2013; 54:103-110

Objectives:

  1. Understand the core principles of biomedical ethics as they apply to capacity evaluation, particularly for pregnant patients.
  2. Identify the third parties who may be affected by a pregnant patient’s ability to make medical decisions.
  3. Understand the unique challenges that consultation psychiatrists face when assessing capacity in pregnant patients.

Relevance:
Questions of medical decision-making capacity during pregnancy are often complicated and have little legal precedent and limited guidance from studies.

 

[T] Clinical Outcomes After Acetaminophen Overdose: A Review of 300 Consecutive Cases
Presenting Author:  Tamara Dolenc, MD
Co-Authors: Nuria Thusius, J. Michael Bostwick

Purpose: Acetaminophen, a readily available non-prescription analgesic and antipyretic, is sold over the counter in bottles containing hundreds of pills. Many patients are unaware that their prescription pain medications also contain acetaminophen. Patients presenting after intentional acetaminophen overdose can suffer significant medical consequences, including liver failure. Indeed, acetaminophen overdose is the leading cause of acute liver failure in the United States, with liver transplantation the only definitive therapy significantly increasing chances of survival for advanced acute liver failure.

Little is known about what proportion of patients go to transplant after overdose. With one of the largest cohorts ever studied, we aim to characterize outcomes after overdose, define the demographics of this group, and identify biological and psychosocial risk factors for severe overdose consequences with the goal of informing consultation-liaison psychiatrists of the best approach to evaluation and treatment of these patients.

Method: We conducted a retrospective chart review study of 300 consecutive patients treated at the Mayo Clinic between 2000 and 2010 in the aftermath of intentional or accidental acetaminophen overdose.

Results: We reviewed the demographics of both intentional and accidental acetaminophen overdose patient cohorts, the context for their overdoses, treatments received, and the full spectrum of clinical consequences and outcomes ranging from minimal toxicity to fulminant hepatic failure, liver transplantation, and death. For both patient groups, we have defined the medical and psychiatric risk factors predictive of increased morbidity and mortality. Similarities and differences between intentional and accidental acetaminophen overdose groups are reviewed.

Conclusions: Consultation-liaison psychiatrists are frequently asked to evaluate patients after intentional acetaminophen overdose or therapeutic misadventure to devise an individualized psychiatric treatment plan. We identify the psychosocial, psychiatric, and medical risk factors leading to increased morbidity and mortality after excessive acetaminophen ingestion. Our findings will assist the consultation-liaison psychiatrist in fashioning appropriate personalized treatment plans for patients who have overdosed on acetaminophen for any reason.

References:
Hodgman MJ, Garrard AR. A review of acetaminophen poisoning. Critical Care Clinics. 2012; 28:499-516.

Chun LJ et al. Acetaminophen Hepatotoxicity and Acute Liver Failure. J Clin Gastroenterol. 2009; 43:342-9.

Larson AM et al. Acetaminophen-induced acute liver failure: Results of a United States multicenter, prospective study. Hepatology. 2005; 42:1364-1372.

Fontana RJ. Acute liver failure including acetaminophen overdose. Med Clin North Am. 2008; 92:761-794.

Objectives:

  1. Be able to discuss the epidemiology of acetaminophen toxicity.
  2. Be able to discuss the protective and risk factors for acetaminophen-related clinical outcomes including acute liver failure, liver loss, liver transplantation, and death.
  3. Be able to apply our findings to fashion the most appropriate individualized treatment plans for patients after intentional or accidental acetaminophen overdose.

Relevance:
Acetaminophen overdose is the leading cause of acute liver failure in the US. Little is known about biological and psychosocial risk factors for severe overdose consequences, including liver loss and death.

 

Identifying Anxiety and Depression in Cardiac Patients: The Results of Systematic Screening
Presenting Author:  Christopher Celano, MD
Co-Authors: Laura Suarez, Andres Caro, Gillian Sowden, Carol Mastromauro, Jeff Huffman

Purpose: Depression and anxiety in cardiac patients are prevalent and independently associated with morbidity and mortality. The American Heart Association recommends routine screening for depression in cardiac patients; however, despite similar consequences due to anxiety, no corresponding screening recommendation exists. We aimed to explore the utility of a three-step approach to identify cardiac inpatients with depression, generalized anxiety disorder (GAD), or panic disorder (PD); understand the predictive value of individual screening items in identifying these disorders; and assess the relative prevalence of these disorders in this cohort.

Methods: An iterative three-step screening procedure was developed to identify depression and anxiety disorders in cardiac inpatients as part of a care management trial. This included an existing four-item "Coping Screen" tool in nursing datasets; a 5-item screen for positive Coping Screen patients (comprised of the Patient Health Questionnaire-2 [PHQ-2], Generalized Anxiety Disorder-2 [GAD-2], and an item about panic attacks); and a diagnostic evaluation using the Patient Health Questionnaire-9 and anxiety modules from the PRIME-MD. We identified the frequency of positive screens and diagnoses of depression, GAD, and PD. To determine which items from the Coping Screen and 5-item screen predicted a disorder, logistic regression analyses controlling for age and gender were performed.

Results: Of the 10,114 patients admitted to the inpatient cardiac units during the study period, 6,209 received the initial Coping Screen, and 579 completed all three steps of the screening procedure. Two-hundred five patients received a psychiatric diagnosis (141 depression, 129 GAD, 29 PD). This represented 30% of patients screened with the 5-item screen and 35% of those patients who underwent disorder-specific screening. Of the Coping Screen items, depressed mood predicted depression, and fear predicted GAD and PD. Four of five items from the 5-item screen predicted GAD and depression, and the panic attack item was predictive of PD.

Conclusions: This study demonstrates that screening cardiac inpatients for depression and anxiety disorders in a systematic fashion is feasible and can appropriately identify patients suffering from depression, GAD, or PD. GAD was equally prevalent with depression in our cohort of patients. As GAD has been associated with poor cardiac outcomes in prior studies, the identification of patients with GAD should continue to be a priority for physicians. PD, on the other hand, had a low prevalence rate and often was comorbid with GAD or depression; therefore, screening for this disorder seems to be relatively low-yield. To streamline the screening process, we would recommend utilizing the first four items of the 5-item screen—which include two items to screen for depression and two items to screen for GAD—in place of the Coping Screen.

Objectives:

  1. Be able to describe the utility and feasibility of a three-step approach to identify depression, generalized anxiety disorder, and panic disorder in cardiac inpatients.
  2. Be able to describe the predictive values of individual screening items in identifying these mood and anxiety disorders in this population.
  3. Be able to identify the relative prevalence rates of these disorders among patients hospitalized for cardiac disease.

Relevance:
This presentation will provide important information about the feasibility and utility of screening for depression, GAD, and PD in cardiac inpatients, a very high risk population.

 

Meta-Analysis of Selective Serotonin Reuptake Inhibitor (SSRI)-Associated QTc Prolongation
Presenting Author:  Scott Beach, MD
Co-Authors:  Christopher Celano, Jeff Huffman

Purpose: Selective serotonin reuptake inhibitors (SSRIs) are the mainstay of pharmacologic treatment for depression and anxiety. Emerging evidence has raised concern that some SSRIs may be associated with QTc prolongation, increasing the risk for lethal arrhythmias. We set out to examine the propensity of SSRIs to prolong the QTc interval via meta-analysis.

Methods: We performed a literature search using PubMed with the following terms: “QT,” “torsades de pointes” and “sudden cardiac death,” combined with terms “antidepressants,” “citalopram,” “escitalopram,” “fluoxetine,” “sertraline,” “paroxetine,” and “fluvoxamine,” for a total of 21 separate searches. We supplemented by hand-searching bibliographies of retrieved studies. All prospective studies reporting data related to QTc intervals prior to and following treatment with SSRIs in adults were ultimately included and two independent reviewers extracted data and critiqued study quality. We then performed a meta-analysis of the included studies to determine the risk of QTc prolongation associated with SSRIs as a class and with individual agents. QTc prolongation with SSRIs was compared to that of placebo in a subset of placebo-controlled studies. QTc prolongation with SSRIs was compared to that of tricyclic antidepressants (TCAs) in a subset of TCA-controlled studies. Finally, QTc prolongation with citalopram was compared to prolongation with each of the other SSRIs in a step-wse fashion using placebo-controlled studies.

Results: Sixteen studies (with 25 distinct data subsets) involving 4292 patients met inclusion criteria and were meta-analyzed. Many studies were found to be of only moderate quality. SSRIs were found to be associated with a small, dose-dependent increase in QTc interval of approximately 6 milliseconds (msec) compared to placebo (6.10 msec [95% confidence interval {CI} 3.47−8.73]; p<.001). TCAs caused a dose-dependent increase that is approximately 7 msec greater than SSRIs (TCA prolongation 7.05 msec [95% CI 3.84−10.27] greater than SSRIs; p<.001). Among individual SSRIs, citalopram was associated with greater QTc prolongation than several other SSRIs.

Conclusions: This meta-analysis confirms that SSRIs as a class are associated with QTC prolongation, though the extent of the prolongation suggests low clinical risk in real-world practice and is significantly less than that of medications commonly known to prolong the QTc. Citalopram appears to prolong the QTc to a greater extent than do other SSRIs, a finding that may warrant caution with its use in high-risk populations.

Objectives:

  1. Understand the relationship between SSRIs and QTc prolongation.
  2. Recognize that citalopram may be more likely than other agents to cause QTc prolongation.
  3. Make informed decisions regarding SSRI use in patients who are at risk for QTc prolongation.

Relevance:
Consult psychiatrists frequently prescribe SSRIs to patients who may be at risk for QTc prolongation. Understanding the relative risk associated with SSRIs is therefore an essential component of practice.

 

Routine Suicide Screening in Triage of an Urban Academic Emergency Department Does Not Identify All Critical Cases
Presenting Author:  Cheryl McCullumsmith, MD, PhD
Co-Authors:  Stephan Meadors, Joseph Carley

Background: In 2008 the Joint Commission created Patient Safety Goal 15, which calls for health care organizations to conduct a thorough screening of patients they believe may be at risk for suicide. This goal was implemented after inpatient suicide was found to be among the top recorded sentinel events, and root cause analysis identified lack of assessment for suicide risk as responsible for roughly 40% of these sentinel inpatient suicides. Patient Safety Goal 15 calls for psychiatric and behavioral health facilities to complete full suicide risk assessments on all patients. It additionally requires that all medical facilities conduct assessments on patients who present with a primary psychiatric complaint. Assessments of individuals with a secondary psychiatric diagnosis/complaint are encouraged but not required. While medical facilities were allowed to implement their own screening systems, some electronic medical record providers integrated the screening process directly into their software.

Objectives: Explore the specificity and sensitivity of suicide screening triage questions used in the University of Alabama at Birmingham's emergency department triage.

Materials and Methods: Study sample was comprised of 204 patients in the emergency department who were seen by the psychiatry department as consults. Participants were screened by the emergency department nursing staff with four suicide-related triage questions: 1) Have you ever received mental health treatment in the past? 2) Do you currently have any thoughts about harming yourself with the intent to die? 3)Do you currently have a specific plan for suicide? 4) Have you ever tried to harm yourself with the intent to die in the past?

During the psychiatric consult process several additional scales were administered including the Beck Suicide Scale, Center for Epidemiologic Studies Scale for Depression, Alcohol Use Disorders Identification Test, and a drug-use screening scale. Positive responses to each of the four suicide screening questions were assigned a value of 1 and a sum score was created that reflected the total number of positive responses for each study subject. The relationships between the triage sum score and scores on the additional scales were analyzed. Predictive demographics of patients not detected by the triage questions were determined by linear regression analysis

Results/Conclusions: All four of the suicide screening questions and the triage summation score correlated highly to the Beck Suicide Scale, but the latter three questions did not correlate with depression, alcohol, or drug-use scales. Many patients with a triage sum >=2 had relatively lower triage levels than might be expected by triage algorithm (3 or 4). Significantly, 45% of individuals with a triage sum score of 0 had Beck Suicide Scale scores > 4, which indicates significant suicide risk. Characteristics of these individuals are examined in detail.

Objectives:

  1. Understand Joint Commission requirements for screening for suicide risk.
  2. Understand current options for suicide screening.
  3. Understand the sensitivity and specificity of routine suicide screening by non-mental health nurses in an academic emergency department's triage.

Relevance:
Suicide screening in the medical setting is controversial and difficult to establish, especially when completed by non-mental health professionals. The utility, specificity, and sensitivity of such screening requires further examination.

 

The Association of Polymorphisms in Corticotrophin-Releasing Hormone Genes with Symptoms of PTSD and Depression in Medical-Surgical ICU Survivors
Presenting Author:  Dimitry Davydow, MD, MPH
Co-Authors:  Ruth Kohen, Douglas Zatzick, Catherine Hough, Wayne Katon

Background: Critical illness survivors have high rates of clinically meaningful posttraumatic stress disorder (PTSD) and depressive symptoms. Critical illnesses are associated with dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, and HPA axis hyperactivity, particularly involving corticotrophin-releasing hormone (CRH), has been associated with increased risk of PTSD and major depression.[1] We sought to determine if Corticotrophin Releasing Hormone Binding Protein (CRHBP, rs10055255) and Corticotrophin-Releasing Hormone Receptor (CRHR1, rs1876831) single nucleotide polymorphisms (SNPs) were associated with risk of PTSD and depressive symptoms following medical-surgical intensive care unit (ICU) hospitalization.

Methods: We extracted DNA for genotyping from saliva samples from a sub-cohort of patients admitted to an ICU for greater than 24 hours who were enrolled in a prospective cohort investigation of post-ICU psychiatric outcomes. Of the 93 saliva samples, 85 yielded enough DNA for genotyping using fluorescence-based methods. Follow-up interviews were conducted via telephone at 3 and 12-months post-ICU. Follow-up included assessment of PTSD symptoms with the PTSD Checklist-Civilian Version (PCL-C) and depressive symptoms with the Patient Health Questionnaire-9 (PHQ-9). We used mixed-model linear regression to determine if the SNPs of interest were associated with 3 and 12-month PTSD or depressive symptoms.

Results: In the sub-cohort of ICU survivors who provided saliva samples, the 3 and 12-month prevalences of substantial depressive symptoms (PHQ-9 ≥ 10) were 34.1% and 17.3%, while the prevalences of 3 and 12-month substantial PTSD symptoms (by PCL-C algorithm) were 17.1% and 13.6%. In unadjusted analyses, being homozygous for the CRHBP rs10055255 T allele was associated with significantly fewer post-ICU PTSD (beta: -10.8, 95% Confidence Interval [95%CI]: -17.7, -3.9; P = 0.002) and depressive symptoms (beta: -3.7, 95%CI: -6.7, -0.7; P = 0.02). Carrying a CRHR1 rs1876831 C allele was associated with significantly more post-ICU depressive symptoms compared to T/T homozygotes (C/T heterozygtes: beta: 6.9, 95%CI: 1.2, 12.6; P = 0.02; C/C homozygotes: beta: 5.8, 95%CI: 0.2, 11.3, P = 0.04), though this SNP was not associated with post-ICU PTSD symptoms. These associations remained significant in analyses that adjusted for age, race, and illness severity at ICU admission. No patients with either substantial PTSD or depressive symptoms at either follow-up time point were homozygous for the CRHBP T allele. Twenty-five (32.9%) patients and 13 (17.3%) patients with substantial depressive symptoms at 3 and 12-months post-ICU had at least one CRHR1 C allele.

Conclusions: Despite a small sample size, our findings suggest a potential role for genetic variants of CRHBP and CRHR1 in the development of PTSD and major depression in the aftermath of critical illness.

Reference:
Binder EB, Owens MJ, Liu W, et al.: Association of polymorphisms in genes regulating the corticotropin-releasing factor system with antidepressant treatment response. Arch Gen Psychiatry 2010; 67:369-379.

Objectives:

  1. Investigate the potential role of the hypothalamic-pituitary-adrenal axis in the development of posttraumatic stress disorder and depression following critical illnesses.
  2. Analyze new evidence suggesting a role for genes that regulate the corticotrophin-releasing hormone in the development of posttraumatic stress disorder and depression in critical illness survivors.
  3. Be able to apply the evidence presented to stimulate work on the development of candidate biomarkers for psychiatric disorders in the aftermath of critical illnesses.

Relevance:
Understanding the potential role of genes that regulate HPA axis activities in development of post-ICU psychiatric disorders is highly relevant to psychosomatic medicine providers who care for these patients.

 

Session B:  Delirium
Moderator:  Thomas W. Heinrich, MD, FAPM

David and Goliath: C-L Psychiatry and the Current State of Delirium Awareness, Prevention, and Management
Presenting Author:  Leo Pozuelo, MD, FACP, FAPM
Co-Authors:  Mariela Herrera-Rojas, Manfred Baumgartner, Debra Kangisser

Purpose: Consultation-Liaison (C-L) psychiatrists are uniquely positioned to assess how diverse specialists and providers deal with delirium. C-L consults are often placed when a misdiagnosis of delirium exists (i.e., hypoactive delirium called in as depression) or the initial treatment strategy for delirium has failed. Concerns of delirium management were presented by C-L psychiatry to the Cleveland Clinic's Quality Patient Safety Institute (QPSI). A Delirium Task Force was convened and an initial Phase I study was performed to assess the current state of delirium awareness, prevention and management at the 1100-bed teaching hospital.

Methods: Under the umbrella of QPSI and the Neurological Institute, an online self-administered survey was designed and distributed to multi-specialty staff physicians, nurses, midlevel providers, and residents/fellows. In addition, project managers assisted in conducting half-hour peer-to-peer structured interviews of non-psychiatric, multi-specialty providers across all staffing disciplines. Online survey results were tallied after a two-week posting on the institution intranet. Peer-to-peer interviews were coalesced for common delirium themes.

Results: 344 online surveys were completed and the following observations stood out: 93% of respondents believed delirium patients require more time and resources than non-delirium patients. 63% of respondents estimated the prevalence of delirium as 20% or less in their patient population. Only 16% of providers used a standardized tool for screening. Only 39% of units or services employed standardized strategies for prevention of delirium. 60% of providers believed there is variation across the institution in management and treatment. Only 7% of providers strongly agreed that delirium is effectively managed in their unit or service.

A total of 59 peer-to-peer interviews were completed and the following themes were detailed: The majority of interviewees could identify at least some aspects of hyperactive delirium. Many respondents indicated no prevention strategies existed and there were mixed perspectives on the effectiveness of local protocols to deal with delirium. Inconsistencies were observed in medication practices and management strategies across settings, shifts, units, and provider types. Barriers were found for identification and treatment of delirium, including lack of algorithms, protocols, education, and patient hand-off. Improvement recommendations included implementing education, protocols, and algorithms. Agreement existed that multidisciplinary teams are needed for improvement in delirium management.

Conclusions: Delirium adversely affects hospital care and there are many opportunities for improvement in delirium awareness, prevention, and management. Providers generally welcomed the institution looking into how to better tackle delirium. Many identified barriers and variations in management can benefit from the expertise of C-L Psychiatry, including provider education, training, and use of standardized care paths. The next Phase II of the Delirium Task Force will address data collection, education, screening tool development, and care path implementation.

Objectives:

  1. Understand how a multidisciplinary task force can help collect information on the current state of delirium awareness, prevention, and management at your institution.
  2. Familiarize the C-L clinician with current attitudes and difficulties clinician colleagues report in delirium knowledge and management.
  3. Learn techniques as to how C-L psychiatrists can assist clinical organizations in cross-discipline quality improvement projects concerning delirium awareness, prevention, and management.

Relevance:
In today’s increasing environment of collaborative care models and accountable care organizations, C-L psychiatrist are uniquely positioned to help guide and outline improved management of comorbid medical conditions, including delirium.

 

Postoperative Subsyndromal Delirium Predicts Development of Full Delirium and Increases Length of Hospital Stay
Presenting Author:  J Jewel Shim, MD, FAPM
Co-Authors: Glen DePalma, Laura Sands, Jacqueline Leung

Introduction: Subsyndromal delirium is a recognized entity that has yet to be well-defined. Previous work has characterized subsyndromal delirium as an alteration in level of consciousness and cognition with severity and number of symptoms not quite reaching threshold for a diagnosis of delirium. This has been quantified by not meeting full criteria either by various diagnostic screening tools, i.e., Confusion Assesssment Method (CAM), or by the diagnostic criteria for delirium from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Opinions have differed in whether subsyndromal delirium is a kind of "predelirium" vs. a distinct clinical syndrome. Studies have demonstrated that outcomes for subsyndromal delirium are between those for patients who never develop delirium and those with full delirium. The purpose of this study was to further characterize subsyndromal delirium in the postoperative setting, whether it predicted development to full delirium, and evaluate specific outcomes such as hospital length of stay, ability to perform Independent Activities of Daily Living (IADL) postoperatively, and cognitive status 30 days after hospital discharge.

Methods: The study was approved by institutional review board and informed consent was obtained from each patient preoperatively. Subjects were all patients 65 and older admitted to a tertiary care academic teaching hospital undergoing major non-cardiac surgery, requiring general anesthesia and a hospitalization for at least 2 days postoperatively. Data were collected from 2001-2012. Postoperative delirium was measured daily using the CAM. Logistic regression was used to examine progression of subsyndromal delirium to delirium and comparison of subjects without any symptoms of delirium, subsyndromal and full delirium was done via the two-sample t-test.

Results: The most common features of delirium were altered level of consciousness and psychomotor disturbance. Subjects with at least two symptoms of subsyndromal delirium on hospital day 1, compared to those with either one or no symptoms, were at higher risk for development to full delirium (p < 0.001). Subjects with even one feature of delirium had a significantly longer length of stay compared to those without any symptoms (p < 0.001). However, neither subsyndromal nor full delirium predicted decline in functioning by IADL assessment, nor did either correlate with performance on cognitive evaluation 30 days after discharge.

Conclusion: Common features of subsyndromal delirium after major non-cardiac surgery included altered level of consciousness and psychomotor disturbance. The number of symptoms of subsyndromal delirium correlated with the subsequent development of full delirium, suggesting it may be a predelirious state. Even one feature of delirium predicted significantly longer length of stay, supporting previous work that symptoms of subsyndromal delirium have significant impact on clinical outcomes. Future studies should further evaluate longer term outcomes of subsyndromal delirium and whether specific symptoms of subsyndromal delirium predict transition to full delirium.

Objectives:

  1. Differentiate between subsyndromal and full delirium.
  2. Recognize the presence of subsyndromal delirium and its significance for immediate clinical outcomes.
  3. Understand the potential impact of subsyndromal delirium on long term functional and cognitive outcomes.

Relevance:
Subsyndromal delirium is a common clinical presentation in the acute hospital setting and has been associated with adverse clinical outcomes.

 

Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS): A New Scale for the Prediction of Moderate to Severe Alcohol Withdrawal in Medically Ill Patients
Presenting Author:  Jose Maldonado, MD, FAPM
Co-Authors:  Yelizaveta Sher, Kelsey Hills-Evans, Heavenly Swendsen, Rachael Talley, Sermsak Lolak, Anne Catherine Miller, Judith Ashbouri

Background: Alcohol use disorder is the most serious substance abuse problem in the US. The prevalence of alcoholism among medically ill patients ranges between 20–81%; about 30% develop alcohol withdrawal symptoms [AWS], requiring pharmacological treatment. Complicated courses of AWS can include withdrawal-related seizures, hallucinosis, and delirium tremens (DTs). DTs occur in 10% of patients with AWS, resulting in death in up to 20% of cases with certain medical comorbidities. Studies demonstrate that alcohol withdrawal is detrimental to the central nervous system as it causes neuronal degeneration and death. Thus, appropriate identification and prevention of alcohol withdrawal in subjects at risk can greatly benefit patients by reducing the risk of brain damage (and thus rate of neurocognitive decompensation), medical comorbidities, and length of hospital and ICU stays. Several tools quantify the severity of clinical AWS (e.g., CIWA, AWSS), but none predict subjects at risk, thus missing the opportunity for timely prophylaxis. To meet this need, we developed a tool to identify those at risk for moderate to severe AWS.

Methods: We identified factors associated with AW severity through a systematic literature review (using Cochrane Databases, PubMed, PsychInfo, and Medline) to identify factors associated with the development and severity of AWS. Based on the findings, we developed a 10-item scale to predict alcohol dependent patients at risk for developing moderate to severe AWS (i.e., seizures and delirium tremens). A pilot study (n=68) showed 100% sensitivity and specificity. We then designed a large prospective trial of 400 consecutive inpatients to test the PAWSS. Subjects were assessed using the PAWSS, while independently assessed daily by nurses with the CIWA-Ar, along with clinical monitoring and measures of autonomic system functioning throughout their admission to determine the presence and severity of AWS. Examiners were blind to each other findings.

Results: We have results for 409 patients, grouped by PAWSS score (Group A: PAWSS <4, low risk for AWS; and Group B: PAWSS >4, high risk for moderate to severe AWS). None of the patients in Group A had elevated CIWA scores or were treated for AWS. Most patients in Group B required some pharmacological treatment. Thus, using a PAWSS cut-off of 4, the tool's sensitivity is 100%, specificity is 98.5%, positive predictive value is 81.5%, and negative predictive value is 100%.

Conclusions: The results of this prospective study show that PAWSS appears to have excellent psychometric characteristics and predictive value. Using PAWSS will help clinicians identify those at risk, and prevent patients in the moderate to severe AWS range. This information may be used to provide prophylactic treatment to those at high risk and thus minimize the potential detrimental consequences of AWS (e.g., sedation, delirium, respiratory depression, intubation) and potentially minimize recidivism of alcohol abuse.

Objectives:

  1. Be able to appreciate the prevalence of alcohol abuse and withdrawal among medically ill individuals and the extent to which it affects medical care and outcomes.
  2. Be able to review the detrimental causes of alcohol withdrawal syndrome and the importance of early prophylaxis.
  3. Be able to understand the psychometric properties and clinical potential of PAWSS.

Relevance:
Alcohol use disorders affect 20–81% of hospitalized individuals; 30% will develop AWS, including seizures and DTs. We developed and tested a tool (PAWSS) to identify medically ill individuals at risk.

 

Team-Based Delirium Care Training: A Systematic Review of the Literature and Recommendations
Presenting Author:  Sanjeev Sockalingam, MD, FRCPC
Co-Authors:  Adrienne Tan, Raed Hawa, Susan Abbey, Brian Hodges

Background: Delirium is highly prevalent in acute care settings and associated with increased morbidity and mortality. Traditional delirium care training programs that have focused on specific disciplines have yielded inconclusive results. Recent delirium treatment guidelines recommend use of a “multi-component intervention delivered by a multidisciplinary team trained and competent in delirium prevention and management.” We conducted a systematic review to identify the evidence for interprofessional (team-based) training programs for delirium care.

Methods: We searched the following databases using the key words “delirium,” “interprofessional,” and “education”: Medline, EMBASE, PsychINFO, Web of Science, and ERIC Institute of Sciences. We also searched MedEdPortal, Best Evidence in Medical Education and official psychiatry, critical care and delirium society websites. Studies were included if they consisted of an education intervention targeting > 2 healthcare professions, were in English, and reported an outcome as classified by Kirkpatrick’s evaluation framework. Study abstracts were reviewed by two independent reviewers to determine study inclusion.

Results: Our search yielded 446 abstracts and 21 warranted further review. A total of 6 studies met the inclusion criteria and sample sizes ranged from 10 to 400. The median number of disciplines involved in the education program was 3. Four studies consisted of educational programs alone and two studies consisted of educational programs coupled with clinical intervention changing delirium care on specific units. Nearly all educational programs incorporated didactic, small group, and case-based discussion instructional methods. In terms of Kirkpatrick’s outcomes, improvements in learner reaction was demonstrated in four studies, and three studies demonstrated improvement in learning (delirium knowledge). The two studies that utilized combined educational and program interventions resulted in improvement in patient outcomes.

Conclusions: Preliminary evidence suggests that interprofessional education programs for delirium care may influence team and patient outcomes. Consultation-liaison psychiatrists are well positioned to champion a team-based approach to delirium care and can build on this evidence. Utilizing conceptual frameworks in interprofessional education and simulation training, we provide recommendations for advancing delirium training for healthcare professionals.

Objectives:

  1. To identify the importance of team-based care in delirium prevention and management.
  2. To contrast the evidence for interprofessional delirium training curricula on learner and clinical outcomes.
  3. To apply the systematic review findings to future team-based delirium training endeavours.

Relevance:
Consultation-liaison psychiatrists play essential roles in delirium education. Attendees will be able to apply these study findings to their current or future delirium training initiatives at their local institutions.

 

Current Practices in the Management of Delirium in Critically Ill Patients: A Report of APM Critical Care SIG Survey
Presenting Author:  June Cai, MD
Co-Authors:  Joseph Rasimas, O. Joseph Bienvenu, Inna D'Empaire, Dimitry Davydow

Background: Delirium affects 70-80% of critically ill patients. Although validated instruments for delirium screening in critically ill patients exist, and trials of antipsychotics for delirium-related psychosis have begun to be conducted, the evidence base for the effective management of critical illness-related delirium remains limited. The Academy of Psychosomatic Medicine (APM) Critical Care Special Interest Group (SIG) sought to understand current practice regarding delirium screening and treatment in critical care settings, as viewed by the APM, by surveying the membership.

Methods: An online survey was conducted between October-November 2012, and consisted of 28 questions focusing on three aspects of critical care delirium management: 1) utilization of evidence-based delirium screening protocols in critical care settings; 2) use of antipsychotic medications for delirium, as well as specific antipsychotics used, by critical care medical providers; and 3) use of evidence-based non-pharmacologic management strategies (e.g., diagnose and treat underlying etiology, pursue early mobilization) for critical care delirium. Survey results were tabulated and bivariate analyses were conducted to examine associations of interest in key aspects of critical care delirium management.

Results: 238 responded to the survey (response rate = 26%). Nearly 90% of respondents were attending physicians, three-quarters had been in practice for at least 6 years, and three-quarters practiced in academic medical centers. Only one-third replied that their critical care settings had a formal delirium screening protocol. Only 27% replied that they used a validated delirium diagnostic instrument in their own clinical practice. Over 70% replied that delirious critically ill patients were already being prescribed antipsychotic medications at least 50% of the time prior to their initial consultation, though only 6% responded that hypoactively delirious patients were routinely being prescribed antipsychotic medications at least 50% of the time. The most common antipsychotic being prescribed by critical care medicine physicians was intravenous haloperidol, followed by quetiapine. Fifteen percent replied that evidence-based non-pharmacologic management strategies for delirium management were never an explicit part of the critical care team's treatment plan, and another 39% replied that non-pharmacologic strategies were only an explicit part of the treatment plan up to 25% of the time. Forty percent replied that their most common initial recommendation was to pursue non-pharmacologic management strategies, and nearly three-quarters replied that they only recommended antipsychotic treatment for hypoactive delirium if the patient was symptomatic. There was a significant association between the critical care setting having a delirium screening protocol and the critical care medical team being more likely to utilize non-pharmacologic management strategies (Fisher's Exact Test, P = 0.009).

Conclusions: Although limited by non-response, the APM Critical Care SIG survey on critical care delirium management highlights that the APM could play an important role in improving the management of delirium in critically ill patients.

Objectives:

  1. Examine the current state of evidence-based practice in the management of delirium in critically ill patients.
  2. Review the findings of the APM Critical Care SIG survey of APM membership on management of delirium in critically ill patients.
  3. Utilize the findings of the APM Critical Care SIG survey to examine the management of delirium in critically ill patients at the learner's care setting.

Relevance:
This presentation is highly relevant to psychosomatic medicine providers who routinely assist in the clinical management of delirious critically ill patients.

 

Session C:  Neuropsychiatry
Moderator:  Jason Caplan, MD, FAPM

A Randomized Controlled Trial (RCT) of Telephone and In-Person Cognitive Behavioral Therapy for Major Depression after Traumatic Brain Injury
Presenting Author:  Jesse Fann, MD, MPH, FAPM
Co-Authors:  Charles Bombardier, Steven Vannoy, Joshua Dyer, Evette Ludman, Kenneth Marshall, Jason Barber, Nancy Temkin

Purpose: Major depressive disorder (MDD) is the most common psychiatric condition experienced by individuals with traumatic brain injury (TBI). Less than half of individuals with TBI and MDD receive any depression treatment and most patients prefer counseling over pharmacotherapy. No RCTs of psychotherapy for MDD after TBI have been published. Common barriers to depression treatment include difficulty with cognition, transportation, mobility, and accessibility. We describe the results from an RCT of telephone administered and in-person cognitive behavioral therapy (CBT) for persons with TBI and MDD.

Methods: One hundred adults with MDD within 10 years of complicated mild to severe TBI were recruited from clinical and community settings throughout the United States and randomized to one of three arms: 1) telephone CBT (CBT-T); 2) in-person CBT (CBT-IP); and 3) Usual Care (UC). We utilized choice-stratified randomization to maximize ecological validity. The CBT intervention consisted of 12 sessions over 4 months. The primary outcomes were change in depression severity on the Hamilton Depression Rating Scale (HAMD) and the Symptom Checklist (SCL-20) at 4 months, assessed by a rater blinded to treatment condition. Adjusted mixed-effects models were used in the analyses. We also assessed rates of MDD remission on the SCID and participants' ratings on the Patient Global Improvement (PGI) scale and satisfaction with care at 4 months.

Results: Fifty-eight subjects received CBT (40 telephone, 18 in-person) and 42 received UC. 53% reported being depressed for >1 year and 38% reported a history of pre-injury MDD. The mean number of CBT sessions received was 9.8 (SD 3.0) for CBT-T and 9.2 (SD 4.0) for CBT-IP. The SCL-20 showed greater sensitivity to change than the HAMD. Therapeutic effects of CBT occurred primarily in the first 2 months. There were no statistically significant differences between the combined CBT and UC groups on the HAMD (p=.38) or SCL-20 (p=.068) over 4 months, although completers of at least 8 CBT sessions had significantly improved SCL-20 depression scores compared to UC (p=.014). The CBT-T group had significantly greater improvement on the SCL-20 compared to the UC group over 4 months (p=.038). Rates of MDD remission on the SCID at 4 months were 70% for CBT-T, 80% for CBT-IP, and 57% for UC (p=.25). CBT-T participants also reported significantly greater symptom improvement on the PGI (p=.014) and satisfaction with depression care (p<.001), compared with the UC group.

Conclusions: Findings from this RCT suggest that CBT for MDD, particularly behavioral activation, may be feasible, acceptable, and efficacious in persons with TBI, but further treatment enhancements may be warranted. Telephone CBT holds particular promise for enhancing access and adherence to treatment without any decline in efficacy. Data on secondary outcomes and potential mediators of treatment efficacy will also be presented.

Objectives:

  1. Apply cognitive behavioral therapy (CBT) strategies to treat depression following traumatic brain injury.
  2. Recognize patient populations who may benefit from CBT.
  3. Investigate potential enhancements to CBT that may further improve treatment outcomes.

Relevance:
Consultation-liaison psychiatrists are often asked to treat major depressive disorder in individuals with traumatic brain injury (TBI), yet evidence-based guidelines are limited.

 

Comparison of Florbetapir PET Scans with CSF Biomarkers in Healthy Control, Mild Cognitive Impairment, or Demented Alzheimer’s Disease Subjects
Presenting Author:  Paula Trzepacz, MD, FAPM
Co-Authors:  Ann Hake, Peng Yu, Shufang Wang, Michael Case, Helen Hochstetler, Michael Witte, Robert Dean

Purpose: We compared two ways to measure beta-amyloid (Aβ) — florbetapir positron emission tomography (FBP-PET) scans and cerebrospinal fluid (CSF) biomarkers — across clinically diagnosed healthy control (HC), mild cognitive impairment (MCI), and demented Alzheimer's disease (AD) subjects.

Methods: Data: Alzheimer's Disease Neuroimaging Initiative (ADNI)-Grand Opportunity and ADNI-2 (downloaded August 2012) for all HC, MCI, or AD subjects with clinical and CSF data collected ±90 days of FBP-PET scans. Variables: demographic (including gender and age), cognitive (including Functional Assessment Questionnaire [FAQ], Geriatric Depression Scale [GDS], Animal Fluency, and Trail-Making-Test Part B-A [TMTB-A]), CSF biomarkers (Aβ and tau), and FBP-PET standard uptake value ratios (SUVRs) (composite and 6 regions of interest). Pearson correlation coefficients were calculated among 13 clinical, 5 CSF, and 7 FBP-PET variables. Multinomial logistic regression modeling (reference: HC subjects) assessed associations between clinical diagnosis and CSF/FBP-PET variables. Likelihood ratio test examined whether adding CSF biomarkers to the model regressing clinical diagnosis on FBP-PET SUVRs significantly improved model fit, and vice versa. Stepwise logistic regression analyses determined which factors predicted clinical diagnoses.

Results: Mean ages were 76.5 (HC, n=187), 72.6 (MCI, n=320), and 75.5 (AD, n=70) years, and subjects were mostly white (93.0%, 92.8%, and 95.7%). The highest observed correlations (׀r׀>0.60) in HC and MCI subjects were FBP-PET anterior and posterior cingulate and composite SUVRs with CSF Aβ, tau/Aβ, and phosphorylated tau/Aβ; in AD subjects were FBP-PET anterior cingulate and composite SUVRs with CSF Aβ. In multinomial logistic regression modeling neither CSF (p=0.096) nor FBP-PET (p=0.675) variables significantly added information to explain clinical diagnostic group in the presence of the other biomarker. Stepwise logistic regression analysis using all clinical and biomarker values selected FAQ, age, GDS, Animal Fluency, and posterior cingulate SUVR as significant predictors for differentiating HC from MCI subjects. When the strongest CSF variable (p-tau/Aβ) was forced into the model, the original predictors except posterior cingulate SUVR remained significant. However, when stepwise logistic regression was performed in MCI and AD subjects, significant predictors for diagnosis were FAQ, tau, and TMTB-A. Forcing the strongest FBP-PET variable (posterior cingulate SUVR) into the model added gender as predictor.

Conclusions: Our findings suggest much overlap among CSF and FBP-PET biomarkers in discerning HC, MCI, and demented AD subjects. More CSF and FBP-PET biomarker relationships were observed in HC and MCI subjects versus AD subjects. No statistically significant gains in information were achieved by combining the biomarker type. Posterior cingulate SUVR was the strongest among CSF and FBP-PET biomarkers for distinguishing MCI from HC subjects in conjunction with functional, depression, and executive measures. When distinguishing MCI from AD subjects, CSF tau was one of the strongest predictors, consistent with the importance of changes in CSF tau as the disease progresses into dementia.

Objectives:

  1. To understand correlations among CSF levels of Aβ and tau and FBP-PET SUVRs for amyloid plaque among HC, MCI, and demented AD groups.
  2. To learn how CSF and FBP-PET biomarkers predict disease group.
  3. To appreciate which CSF and FBP-PET biomarkers combine with clinical variables to predict clinical diagnosis of HC, MCI, or demented AD subjects.

Relevance:
Biomarkers assessing beta-amyloid are important when diagnosing Alzheimer’s disease. We compared florbetapir-PET scans, CSF biomarkers, and clinical indices to distinguish healthy, mild cognitive impairment, and demented Alzheimer’s disease subjects.

 

In-Hospital Acute Stress Symptoms Are Associated with Poorer Cognitive Functioning One Year after Medical-Surgical ICU Admission
Presenting Author:  Dimitry Davydow, MD, MPH
Co-Authors:  Douglas Zatzick, Catherine Hough, Wayne Katon

Background: Millions of Americans are admitted to intensive care units (ICUs) annually. Prior studies have found that cognitive dysfunction is common in ICU survivors. Yet, relatively little is known about potentially modifiable risk factors for longer-term post-ICU cognitive impairment. This study sought to determine if in-hospital acute stress symptoms are associated with poorer 12-month cognitive functioning among ICU survivors.

Methods: We prospectively enrolled 150 non-trauma patients without cognitive impairment or a dementia diagnosis admitted to an ICU for ≥ 24 hours. Demographics and clinical information were obtained through medical record review and in-person interview. The baseline interview included assessment of acute stress symptoms, our independent variable of interest, with the Posttraumatic Stress Disorder Checklist-civilian version (PCL-C). Our outcome of interest, cognitive function, was assessed using the modified Telephone Interview for Cognitive Status (TICSm) which was administered at a 12-month telephone follow-up interview. We used multiple linear regression to examine unadjusted and adjusted associations between in-hospital acute stress symptoms and 12-month cognitive functioning.

Results: Follow-up interviews were completed with 120 (80%) patients. Patients who did not complete 12-month follow-up had a higher in-hospital mean PCL-C score than those who completed follow-up (34.8 vs. 29.8, F = 3.89, P = 0.05). In unadjusted analyses, a higher in-hospital PCL-C score was associated with a significantly lower 12-month TICSm score (beta: -0.1, 95%CI: -0.2, -0.004; P = 0.04). When we adjusted for patient baseline characteristics (e.g., age, sex, race, education, marital status, lifetime major depression, medical comorbidity, problem drinking, problem drug use, and lifetime traumatic event exposures), a higher in-hospital PCL-C score remained associated with a significantly lower 12-month TICSm score (beta: -0.1, 95%CI: -0.2, -0.01; P = 0.04). In the final model that adjusted for both patient and in-hospital clinical characteristics of the ICU admission (e.g., illness severity; requirements for mechanical ventilation, major surgery, and blood product transfusions; presence of probable delirium; and receipt of benzodiazepines, opioids, antipsychotics, and antidepressants), a higher in-hospital PCL-C score was independently associated with a lower 12-month TICSm score (beta: -0.1, 95%CI: -0.2, -0.01; P = 0.03). Of the individual 12-month TICSm domains, higher in-hospital PCL-C scores were associated with worse performance in attention/calculation (t = -2.81, P = 0.006) and delayed recall (t = -2.1, P = 0.04), but not with any other TICSm domain.

Conclusions: In-hospital acute stress symptoms are independently associated with poorer cognitive functioning 12 months following a medical-surgical ICU admission. Efforts to incorporate screening of medical-surgical ICU survivors for acute stress symptoms into routine care following critical illnesses, as well as additional research into the mechanisms linking PTSD symptoms, critical illnesses, and cognitive impairment, are crucial.

Objectives:

  1. Be able to analyze the existing literature on the epidemiology of cognitive dysfunction in critical illness survivors.
  2. Be able to investigate the association of in-hospital acute stress symptoms, a potentially modifiable risk factor, with longer-term poorer cognitive functioning in critical illness survivors.
  3. Be able to apply the findings of this presentation to one's clinical practice as it relates to performing psychiatric consultations among critical illness survivors.

Relevance:
Acute stress symptoms, which are modifiable and may increase risk of longer-term cognitive dysfunction in critical illness survivors, are highly relevant to psychosomatic medicine providers who treat these patients.

 

[T] Psychiatric Manifestations and Management of Anti-NMDA Receptor Encephalitis
Presenting Author:  Jennifer Kruse, MD
Co-Authors:  Jessica Jeffrey, Michael Davis, John Brooks

Purpose: Anti-NMDA receptor encephalitis (anti-NMDARE) is a condition that was formally described in 2007 and includes a diverse range of both psychiatric and neurologic symptoms (e.g., psychosis, agitation, catatonia, seizures, abnormal movements, memory disturbance, etc.). Symptoms progress to include unresponsiveness and autonomic instability. Anti-NMDARE is unique in that 77% of patients turn to psychiatrists for initial diagnosis and treatment. However, many psychiatrists are not aware of the disorder, and there is sparse literature summarizing treatment strategies for psychiatric symptoms.

Method: This paper provides a comprehensive review of anti-NMDARE that is intended to help improve diagnosis and treatment of this disorder. The literature review includes specifics regarding the recognition of psychiatric manifestations of anti-NMDARE as well as a review of treatment strategies reported to date. In addition, two case reports are described to provide a clinical context for the literature review.

Results: The most prominent psychiatric symptoms of anti-NMDARE are psychosis, agitation, insomnia, and catatonia. Although these symptoms seem nonspecific, their rapid emergence in the absence of past history of psychiatric disorders should raise concern for anti-NMDARE, which is diagnosed by serum or CSF detection of NMDAR antibody. Neuroleptics are helpful for management of psychosis and agitation in some instances, but also can exacerbate anti-NMDARE movement abnormalities. Diphenhydramine and benzodiazepines are helpful for agitation and insomnia; the anticholinergic affinity of diphenhydramine may also treat dystonias or parkinsonism associated with anti-NMDARE. Benzodiazepines and ECT have been used successfully to treat anti-NMDARE associated catatonia.

Conclusions: Psychiatrists play a prominent role in the treatment of anti-NMDARE and can contribute to a more critical role in its diagnosis. Recognizing the abrupt onset of the initial psychiatric symptoms of anti-NMDARE enables diagnosis as well as appropriate psychiatric and neurological treatment to begin sooner in the disease course. Careful selection of pharmacological interventions can improve multiple symptoms and alleviate suffering. Given the relatively recent recognition of anti-NMDARE, improved awareness amongst psychiatrists is critical.

References:

1. Dalmau J, Gleichman AJ, Hughes EG, Rossi JE, Peng X, Lai M, et al. Anti-NMDA-receptor encephalitis: Case series and analysis of the effects of antibodies. Lancet Neurol 2008, Dec; 7(12):1091-8.

2. Dalmau J, Lancaster E, Martinez-Hernandez E, Rosenfeld MR, Balice-Gordon R. Clinical experience and laboratory investigations in patients with anti-nmdar encephalitis. Lancet Neurol 2011, Jan; 10(1):63-74.

3. Chapman MR, Vause HE. Anti-NMDA receptor encephalitis: Diagnosis, psychiatric presentation, and treatment. Am J Psychiatry 2011, Mar; 168(3):245-51.

4. Mann A, Machado NM, Liu N, Mazin AH, Silver K, Afzal KI. A multidisciplinary approach to the treatment of anti-nmda-receptor antibody encephalitis: A case and review of the literature. J Neuropsychiatry Clin Neurosci 2012, Mar 1; 24(2):247-54.

5. Braakman HM, Moers-Hornikx VM, Arts BM, Hupperts RM, Nicolai J. Pearls & oy-sters: Electroconvulsive therapy in anti-nmda receptor encephalitis. Neurology 2010, Sep 7; 75(10):e44-6.

Objectives:

  1. Recognize common presenting symptoms of anti-NMDA receptor encephalitis.
  2. Suspect anti-NMDA receptor encephalitis when common presenting symptoms are present, and refer patients for additional diagnostic work-up when indicated.
  3. Apply careful pharmacologic interventions for psychiatric symptoms of anti-NMDA receptor encephalitis.

Relevance:
Consultation-liaison psychiatrists are likely to be consulted to provide psychiatric diagnostic assessments and treatment recommendations for patients with anti-NMDA receptor encephalitis, both before and after a diagnosis is made.

 

Psychological Profiles of Patients with Behavioral Spells and Treatment-Resistant Epilepsy: Identifying Targets for Cognitive and Behavioral Symptom Management
Presenting Author:  Danielle Koby, PhD
Co-Authors:  Jackie Micklewright, Marietta Hoogs, Emily Necrason, Greg Worrell, Richard Seime, Max Trenerry, Jeffrey P. Staab, Kristin Vickers-Douglas, Cindy Nelson

Purpose: Patients admitted for video-EEG monitoring, including those with treatment-resistant epilepsy and behavioral (non-epileptic) spells, possess significant medical and psychiatric complexity. Overall symptom burden, resultant disability, and healthcare utilization remain high within these two patient groups despite widespread recognition and treatment of co-occurring depression and anxiety. The current study was undertaken to identify more complex psychological profiles in epilepsy and behavioral spells, to provide specific targets for cognitive and behavioral symptom management.

Methods: Three hundred (300) consecutive adult patients admitted to the St. Mary’s Hospital Epilepsy Monitoring Unit (EMU) between June 2009 and December 2010 participated in a study of emotional well-being and quality of life. Medical records were reviewed, and standardized self-report measures were completed during inpatient stays including the Beck Depression Inventory-II (BDI-II), Generalized Anxiety Disorder 7-Item Screener (GAD-7), Short Health Anxiety Inventory (SHAI), and Quality of Life in Epilepsy 31-Item Survey (QOLIE-31). Additional self-report data recorded somatic vigilance, history of trauma and abuse, patterns of emotional expression, and perceived disability. Multivariate analyses were used to assess the relationship of clinically significant levels of anxiety and depression to other variables.

Results: Among 283 participants, 106 (37%) patients had video-EEG confirmed behavioral spells while 106 patients had epilepsy (without spells). Total scores on the QOLIE-31 were uniformly poor across both groups while patients with behavioral spells displayed significantly lower overall quality of life (p= .033) and energy/fatigue subscale (p= .037) scores (F = 2.39, p = .028). Both patient groups also endorsed mild, clinically significant symptoms of depression while these were worse in spells (mean= 18.9, SD = 11.2) compared to epilepsy (mean = 15.4, SD = 10.1, F = 5.3, p= .023). While GAD-7 scores indicated no clinically significant anxiety (e.g., worry, panic) in either group, only patients with behavioral spells displayed significant levels of health anxiety on the SHAI (mean = 14.6, SD = 7.2, p= .045).

Conclusions: Consistent with previous research, symptoms of mild depression and poor quality of life were present in patients with behavioral spells and epilepsy, and worse among patients with spells. Overall quality of life scores were considerably lower in the current study compared to previous research, likely reflecting symptom severity among patients at this tertiary care referral center and illustrating the need for additional symptom management interventions. While overall symptoms of anxiety (e.g., worry, panic) were similarly mild and not clinically significant in either group, patients with spells displayed levels of health anxiety similar to those with clinically significant anxiety disorders. Future analyses of the association between health anxiety, history of trauma and abuse, somatic vigilance, and patterns of emotional expression are expected to refine targets for behavioral treatment, improving the effectiveness and efficiency of patient care.

Objectives:

  1. Recognize distinct characteristics among subgroups of patients presenting for video-EEG monitoring and diagnosed with behavioral spells rather than epilepsy.
  2. Identify specific targets for cognitive and behavioral intervention among patients with behavioral spells.
  3. Formulate a cognitive-behavioral approach to treatment among patients with behavioral spells tailored to presenting psychological characteristics and symptoms.

Relevance:
Applied to psychosomatic medicine, healthcare reform must include identification of more immediate and efficient targets for treatment among patients with behavioral spells, a historically heterogeneous, costly, and challenging patient population.

 

Venlafaxine XR for Major Depression and Pain after Spinal Cord Injury: A Multi-site Randomized Control Trial
Presenting Author:  Jesse Fann, MD, MPH, FAPM
Co-Authors:  Charles Bombardier, J Scott Richards, Allen Heinemann, Catherine Wilson, Ann Marie Warren, Lawrence Brooks, Nancy Temkin, Denise Tate

Purpose: Depression and pain are highly prevalent and associated with negative outcomes in individuals with spinal cord injury (SCI). Antidepressant medications are used routinely to treat depression, yet no placebo-controlled antidepressant trials have been published in this population. We sought to examine the efficacy and tolerability of venlafaxine XR (VFN) for major depressive disorder (MDD) and pain in people with SCI.

Methods: Twelve-week, multi-site, randomized, double-blind, placebo-controlled trial (Project to Improve Symptoms and Mood after SCI, PRISMS). Randomization was stratified by site, prior history of MDD, and lifetime history of substance dependence. Participants were recruited from outpatient clinics at 6 SCI treatment centers in the US, were 18-64, at least one month post-SCI, with MDD or dysthymic disorder. The primary outcome was the Hamilton Depression Rating Scale (HAMD 17-item, with Maier subscale, which focuses on core depression symptoms and excludes somatic symptoms) at 12 weeks. Pain intensity and interference were assessed with 0-10 numerical analogue rating scales. Quality of life was assessed at 12 weeks.

Results: Six sites screened 2536 people and 133 were randomized to treatment vs. control. Participants were 74% male, on average 40 years old and 11 years post-injury; 47% had cervical injuries, 53% had ASIA A (complete) SCI, 25% had 2+ prior MDD episodes, and 99% had current MDD. Common comorbidities included chronic pain (94%), significant anxiety (58%), and history of substance dependence (44%). Only 7 (5%) did not provide 12-week primary outcome data. The most common emerging/worsening side-effects were sedation, vivid dreams, flatulence, headache, dry mouth, and dizziness. Mixed effects models revealed no significant differences between the VFN and placebo control groups on improvement in HAMD-17 from baseline to 12 weeks (p=.4). There was a significant effect on the HAMD Maier subscale (p=.02). There was a trend for a larger proportion of people with a history of substance dependence to achieve remission (HAMD-17<8) on VFN (50%) compared to placebo (26%; p=.06), an effect that was statistically significant among those who completed the intervention (p=.04). Non-neuropathic pain intensity and pain interference responded significantly better to VFN than to placebo (p=.01). This finding did not generalize to neuropathic pain. Subjects on VFN had significantly better functioning on the Sheehan Disability Scale at 12 weeks, compared to placebo (p=.005).

Conclusions: VFN is well-tolerated and may be an effective antidepressant for certain SCI subgroups with depression, such as those with a history of substance dependence. Optimal treatment of MDD after SCI may require alternative (e.g., cognitive, behavioral, physical activity), combined, or stepped treatment approaches. VFN may be an effective adjunctive treatment for non-neuropathic pain in the context of depression. The HAMD-17 may be a suboptimal outcome measure in this population. Research is needed to confirm these hypotheses.

Objectives:

  1. Apply pharmacologic strategies to treat depression following spinal cord injury (SCI).
  2. Recognize SCI populations who may benefit from venlafaxine XR.
  3. Learn methodological strategies for studying depression in this patient population.

Relevance:
Consultation-liaison psychiatrists are often asked to treat major depressive disorder in individuals with spinal cord injury (SCI), yet evidence-based guidelines are limited.

 

Session D:  Physical Symptoms & Health
Moderator:  David Katzelnick, MD

[T] A Psychiatric Consultant’s Field Guide for Creating Behavioral Plans: The NEEDS MET Method
Presenting Author:  Kathryn Norfleet, MD
Co-Author:  Alexander Thompson

Purpose: “Difficult” patients exhaust our capacity for empathy when attempts to provide necessary medical care are met with entitled demands, inappropriate requests, treatment sabotage, and self-destructive refusal to participate in care [1]. A defining characteristic of these patients is the presence of difficult personality styles [2]. This includes frank personality disorders as well as maladaptive character traits exaggerated during the stress of acute medical illness [3]. Poor coping results in behavior that makes medical treatment difficult or even impossible. Without a comprehensive and consistently implemented behavior care plan, maladaptive patient behaviors result in frustrated providers giving prolonged and poor patient care. We propose and demonstrate a generalizable method for creating behavior care plans that address maladaptive patient behaviors in the general hospital.

Methods: We completed a detailed PubMed review of the literature addressing difficult patient management. This was assimilated with our own clinical experiences to create a behavioral planning method. Implementation of this method is demonstrated by its application on a difficult patient case.

Results: We created the "NEEDS MET" method to serve two purposes. First, it guides creation of a comprehensive and individualized plan for managing patients’ maladaptive behaviors according to the patient’s problems (NEEDS): No motivation, Emotional dysregulation, Entitlement, Demands, Dangerous/ Disruptive, and Splitting. Second, it outlines the essential elements of support the consulting psychiatry team provides to the medical team so that the plan might work (MET): Modeling implementation of the plan, Education of the team regarding patient behaviors, and Talking with the team to validate the difficult situation they are in with the patient. We demonstrate the application of this method to a narcotic-dependent man with a severe cluster B personality disorder being treated on a vascular surgery service for a femoral artery-infected pseudoaneurysm. Due in part to bad behaviors and addiction, care had reached a stalemate marked by nursing apathy, surgeon frustration, limited forward progress on basic medical fronts (like getting out of bed), and the use of over 300mg of morphine equivalent and 20mg lorazepam equivalents a day. Our team developed a straightforward behavioral plan based on the NEEDS MET method that resulted in substantial patient improvement and improved provider distress and empowerment.

Conclusions: In this case example, effective implementation of the NEEDS MET method results in decreased patient and provider suffering, allowing for appropriate medical care in even the most challenging circumstances in the general hospital. We discuss common challenges with behavior plan implementation. Future research should aim to systematically assess whether application of the NEEDS MET method significantly effects patient and provider satisfaction and patient outcomes (like length of stay).

Objectives:

  1. Discuss what is difficult about “difficult” patients and how that information can inform the development of behavioral plans to manage challenging inpatients.
  2. Describe a method of behavioral planning that can be used by consulting psychiatrists in a wide variety of vexing clinical situations. Detail how this is applied in one illustrative case.
  3. Describe how this behavioral planning method could be formally researched to better develop a widely used and trusted way consulting psychiatry teams help hospitals better care for difficult patients.

Relevance:
Developing and implementing effective behavioral plans for difficult inpatients is a critical clinical skill that is not systematically taught or applied. We demonstrate a generalizable way to develop behavior plans.

 

A Randomized Controlled Trial of CBT vs. Fluoxetine vs. Placebo vs. Joint Therapy for Hypochondriasis
Presenting Author:  Brian Fallon, MD
Co-Authors:  Arthur Barsky, David Ahern, Martina Pavlicova, Iordan Slavov

Hypochondriasis is a disabling disorder for which the relative benefit of CBT vs. Fluoxetine (FLX) vs. Joint CBT/FLX as interventions is unknown.

Methods: 195 subjects with DSM-IV Hypochondriasis were randomly assigned to one of four treatment conditions: FLX, CBT, Placebo, FLX+CBT. Primary outcome assessed percentage of responders and magnitude of improvement on hypochondriasis measures (Whiteley Index [WI] and H-YBOCS-M) at 24 weeks. Secondary outcome assessed functional status, quality of life, somatic symptoms, medical utilization, and other psychopathology. A longitudinal mixed effects model was used for the primary data approach and for comparing symptoms over the course of treatment A Cochran-Armitage trend test was used to test for the hypothesized linear trend that “placebo” is inferior to each of the single active treatments (which will be equivalent, FLX=CBT) which in turn will be inferior to the combination treatment (FLX+CBT).

Results: Assessed categorically with 25% improvement as minimum threshhold for responders, neither fluoxetine nor CBT were significantly better than placebo. Assessed as a continuous measure, fluoxetine was significantly more effective than placebo on the WI but not on the H-YBOCS-M, while CBT was not more effective than placebo on either measure. The hypothesized linear trend was supported — joint therapy performed better than the two active therapies, which in turn performed better than placebo. When the severity threshold for “responder” status was increased to 30, 40, or 50%, fluoxetine consistently performed significantly better than placebo.

Analysis of the anxiety measure (STAI) showed a strong interaction effect between time and treatment condition (p=.0096), with significant improvement for FLX vs. PBO and for FLX/CBT vs. PBO. The depression measure (BDI) did not show a significant time x treatment condition interaction. There were no significant differences across treatment conditions in somatization (PHQ-15), physical functioning and role impairment (SIP), or quality of life and well-being (Q-LES-Q ).

Conclusion: Our study provides support for the use of fluoxetine as a treatment for hypochondriasis and it raises questions about the role of CBT. This study also demonstrates that many patients continue to suffer with substantial hypochondriasis despite well-conducted treatment with fluoxetine and/or CBT. Future studies should examine other approaches for the treatment of this distressing and disabling condition.

Objectives:

  1. Be better informed in choosing therapies for patients with hypochondriasis.
  2. Learn the key aspects of CBT for the treatment of hypochondriasis.
  3. Learn how to use pharmacotherapy in treating patients with hypochondriasis.

Relevance:
This presentation addresses the central psychopathology of many patients seen by consultation-liason psychiatrists — those with somatization and illness anxiety.

 

Associations Between Antidepressant Adherence and Patient-Provider Trust, Shared Decision-Making, and Communication among Adults with Diabetes: Diabetes Study of Northern California (DISTANCE)
Presenting Author:  Amy Bauer, MD, MS
Co-Authors:  Melissa Parker, Wayne Katon, Nancy Adler, Alyce Adams, Howard Moffett, Dean Schillinger, Andrew Karter

Purpose: Among adults with diabetes, patients' trust in their provider, shared decision-making, and overall quality of communication with their provider have been associated with cardiovascular medication adherence. What is not known is whether these potentially modifiable characteristics of the patient-provider relationship are also associated with adherence to antidepressant medications. In this study, we examined whether the patient-provider relationship is associated with antidepressant adherence among adults with diabetes.

Methods: Participants include an ethnically-stratified random sample of adults with diabetes answering a comprehensive survey from the DISTANCE Study (n=20,188).[1] The survey included 8 items measuring different aspects of the patient-provider relationship: 2 items from the Trust in Physicians Scale, 2 items from the Interpersonal Processes of Care Instrument measuring shared decision making, and an overall communication quality measure based on 4 items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Eligibility was limited to 2040 participants who were prescribed bupropion, mirtazapine, an SSRI, or an SNRI with no prior dispensing of an antidepressant medication in the preceding 365 days. Outcomes included 2 validated measures of adherence [2]: early non-persistence (never refilling index antidepressant or alternative); and new prescription medication gap (NPMG; proportion of time that the person is without medication during 12 months after prescription date). Analyses were adjusted for age, gender, race/ethnicity, income, diabetes complications, and depression history.

Results: Patients were less likely to ever refill prescribed antidepressant medication if they reported less trust in physician (2 items: RR 1.21, p=0.08 and 1.29, p=0.02) and less shared decision-making (2 items: RR 1.34 and 1.39, ps<0.01), but not if they reported worse overall communication. Overall poorer adherence during the 12 months after prescription receipt was observed for patients reporting less trust [2 items: 46% versus 41% of days without medications (p=0.04); and 46% versus 40% (p<0.01)] and less shared decision-making as measured by 1 of the 2 items (45% versus 41%, p=0.02), but not for patients reporting worse overall communication.

Conclusions: Among adults with diabetes, lower trust or lack of shared decision-making demonstrated significant associations with antidepressant non-adherence. Communication patterns that promote trust and participation in shared decision-making were more predictive of antidepressant adherence than overall communication quality. The patient-provider relationship is potentially modifiable, and these findings suggest that the interpersonal aspects of care may be important for antidepressant adherence. It is possible that adherence could be improved if providers prioritize efforts to foster trust and a positive therapeutic alliance through shared decision-making with patients. Further understanding of the connections between patient characteristics, patient-provider relationship elements, and medication adherence is a pressing public health concern.

References
1. Moffet et al. Int J Epidemiol 2009; 38(1):38-47.
2. Karter et al. Health Serv Res 2009; 44:5:1640-61.

Objectives:

  1. Recognize that different elements of patient-provider relationships have distinct associations with antidepressant medication adherence.
  2. Describe associations between patient-provider communication, trust, shared decision-making, and antidepressant medication adherence among diabetic adults.
  3. Understand how different patterns of association suggest that intervention strategies targeting interpersonal aspects of patient-provider relationships may be more likely to succeed than strategies targeting communication in general.

Relevance:
Awareness of the importance of patterns of patient-provider communication is critical for consultation-liaison psychiatrists, who are well-positioned to improve the effectiveness of depression treatment for patients with diabetes.

 

Cognitive-Behavioral Group Treatment for a Range of Functional Somatic Syndromes: Lessons Learned from the STreSS-1 Trial
Presenting Author:  Andreas Schröder, MD, PhD

Purpose: Many specialty-specific functional somatic syndrome diagnoses exist to describe people who are experiencing so-called medically unexplained symptoms [1,2]. Cognitive-behavioral therapy (CBT) is effective in the management of such syndromes; however, it is rarely available [3]. Both the fragmented nature of care imposed by different specialist medical clinics and the unacceptability to patients of referral to mental health services pose important obstacles [4].

Methods: To overcome these barriers, we developed a CBT suitable for group treatment of people with different functional somatic syndromes (STreSS, Specialized Treatment for Severe bodily distress Syndromes), and tested its efficacy in a randomized trial (clinicaltrials.gov, NCT00132197).[5] Patients were grouped under the unifying diagnostic category of bodily distress syndrome, multi-organ type [2]. The main results have been published recently; in this paper, we will discuss the rationale of STreSS, including likely mechanisms of action, in the light of syndrome-specific interventions. Moreover, preliminary data on cost-effectiveness of STreSS will be presented.

Results: The group format was well accepted. STreSS was moderately more effective in improving self-rated physical health than enhanced usual care, with effect-sizes comparable to individually delivered and syndrome-specific CBT. The majority of patients qualified for several functional somatic syndrome diagnoses as well as somatoform disorder diagnoses, and patients' main diagnosis did not moderate outcome.

Conclusion: STreSS provides a promising model for the management of patients with various severe functional somatic syndromes, and may be preferable to the implementation of different specialized treatments for single functional somatic syndromes in each secondary medical care service. However, the group format and the broad inclusion criteria may limit the use of syndrome-specific interventions and hinder the optimization of treatment by use of individually-tailored therapeutic strategies. Advantages and disadvantages of our approach will be discussed.

References:

1. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999; 354(9182):936-939.

2. Fink P, Schröder A. One single diagnosis, Bodily distress syndrome, succeeded to capture ten diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res 2010; 68:415-426.

3. Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet 2007; 369(9565):946-955.

4. Schröder A, Fink P. Functional somatic syndromes and somatoform disorders in special psychosomatic units: organizational aspects and evidence-based treatment. Psychiatr Clin North Am 2011; 34(3):673-687.

5. Schröder A, Rehfeld E, Ornbol E, Sharpe M, Licht RW, Fink P. Cognitive-behavioural group treatment for a range of functional somatic syndromes: randomised trial. Br J Psychiatry 2012; 200(6):499-507.

Objectives:

  1. Cognitive-behavioral therapy is effective in the management of so-called functional somatic syndromes (fibromyalgia, chronic fatigue syndrome, etc.).
  2. The STreSS intervention is a generic cognitive-behavioral group treatment for people with different severe functional somatic syndromes. STreSS focus specifically on dysfunctional illness perceptions and illness behaviors.
  3. It is it is feasible and acceptable to patients and physicians to implement a common treatment for different severe functional somatic syndromes.

Relevance:
Psychiatrists have an important role to play in the management of people with functional somatic syndromes / somatic symptom disorders, and should more frequently engage in such treatment.

 

Preoperative Screening Polysomnogram (PSG) of a Large Cohort of Bariatric Subjects Identifies Three Populations with Distinct Types of Regression of Their Apnea-Hypopnea Index (AHI) on BMI
Presenting Author:  Xavier Preud'homme, MD
Co-Authors:  Alfonso Torquati, Ranjan Sudan, Dana Portenier, Andrew Krystal

Purpose: Because undiagnosed obstructive sleep disorder (OSA) is associated with increased postoperative morbidity, the Duke Weight Loss Surgery Center refers their subjects for preoperative screening polysomnography.

Methods: Based on their polysomnographic studies, 235 consecutive referrals were separated into 3 groups: 91 needing no further management (38.7%), 94 whose sleep study was split (40%), and 50 needing to come back to be titrated (21.3%). Regression of AHI on BMI was analyzed across groups.

Results: Females constituted the majority, with 193 for 42 males; however, no gender difference was found for age with a mean of 44.7 years (p=0.23); BMI with a mean of 48.8 kg/m2 (p=0.06); or subjective report of daytime sleepiness with a mean Epworth score of 9.4 points out of a total of 24 (p=0.80). Overall, PSG showed a mean AHI ± SD of 26.4 ± 32.8 per hour corresponding to moderate OSA (AHI of 15-30) and where >=15 per hour is the usual indication for treatment by CPAP. A total of 144 (61.3%) needed CPAP though 166 (70.7%) presented with an AHI of at least 5 per hour. Yet, mean BMI or Epworth scores were not significantly different across groups. Linear modeling of the diagnostic AHI for all subjects as a function of BMI, neck circumference, age, and Epworth score yielded a statistically significant model (F=11.42, p< 0.0001) retaining all independent variables except age. However, the regression of the AHI on BMI was profoundly different across groups. AHI only increased with BMI (as classically described) in the SPLIT group (mean AHI: 47.2), the other two groups showed no regression despite statistically different mean AHI (3.8 versus 31.0 per hour).

Conclusions: We duplicated for the first time in a large cohort of 235 bariatric subjects referred preoperatively for a formal sleep study, the previously published proportion of 70% of morbidly obese subjects being diagnosed with OSA as defined by an AHI >= 5/hour, which led in our sample to a decision to treat with CPAP in 61.3%. Moreover, this preoperative screening allowed to distinguish three groups: those morbidly obese subjects needing no further management, those whose sleep study was split, and those needing to come back to be titrated. Though the mean BMI was not statistically different across those three groups, the regression of AHI on BMI was clearly different, supporting three distinct populations. Further studies are needed to determine whether this impacts the postoperative course.

Objectives:

  1. To present the high prevalence of obstructive sleep disorder in the morbidly obese and thus the usefulness of preoperative screening.
  2. To review the need to initiate preoperative treatment with CPAP in the morbidly obese.
  3. To demonstrate three different populations can be delineated amongst the morbidly obese in terms of how the AHI relates to the BMI.

Relevance:
Despite similar BMI, morbidly obese subjects can be distinguished into three distinct categories varying from those without OSA to those for whom BMI does not contribute to their OSA severity.

 

Session E:  Psycho-Oncology
Moderator:  Rachel Lynn, MD

Advanced Cancer as a Risk for Initial Onset and Recurrent Episodes of Major Depression
Presenting Author:  Fremonta Meyer, MD
Co-Authors:  Kalen Fletcher, Holly Prigerson, Ilana Braun, Paul Maciejewski

Objective: Major depression adversely influences health communication, quality of life, and survival in patients with advanced cancer. Prior research provides limited insight into how advanced cancer patients differ from the general population in risk for developing a major depressive episode (MDE). This study aims to determine whether advanced cancer poses distinct risks for initial and recurrent MDEs.

Method: Advanced cancer patients (N=628) from Coping with Cancer were compared to propensity-weighted general population controls (N=9,282) from the National Comorbidity Survey Replication. Odds ratios for current MDE with prior MDE, advanced cancer, and the interaction between prior MDE and advanced cancer were estimated using logistic regression analysis.

Results: Advanced cancer patients were more likely to have a current MDE [OR=3.5, 95% CI = (2.5-4.9); p<0.001] than demographically similar controls. Prior MDE modified the association between advanced cancer and current MDE [OR=0.055, 95% CI = (0.024 - 0.127); p<0.001]. Cancer patients were more likely than controls to have an initial MDE [OR=27.3, 95% CI = (14.8 - 50.4); p<0.001], but no more likely than controls to have a recurrent MDE [OR=1.5, 95% CI = (0.9 - 2.6); p=ns]. Nearly two-thirds (64.4%) of current MDEs in patients were initial onset, whereas the vast majority (91.8%) of current MDEs in controls were recurrent.

Conclusions: Advanced cancer increases risk of an initial MDE, but does not affect risk of a recurrent MDE. This suggests the importance of screening widely for depression as opposed to identifying presumably high-risk subgroups of advanced cancer patients with psychiatric histories.

Objectives:

  1. Analyze how an advanced cancer diagnosis might differentially affect the risk of initial vs. recurrent major depressive episodes.
  2. Apply epidemiologic evidence regarding the differential risk of initial and recurrent major depressive episodes in order to design screening programs in the advanced cancer population.
  3. Utilize data regarding the types of depressive episodes and the effects of major depression on cancer outcomes when advocating for institutional consultation services.

Relevance:
This presentation provides important epidemiologic data on depression in advanced cancer patients and will assist clinicians in consulting on metastatic cancer patients and designing outpatient psychosocial screening programs.

 

Comparison of Psychiatric Medication Use Among Nationally-Respresentative Long-Term Cancer Survivors and Controls
Presenting Author:  Ilana Braun, MD
Co-Authors:  Sowmya Rao, Fremonta Mayer, Giuseppe Fedele

Context: Cancer survivors are rapidly increasing in numbers, prompting inquiries into whether they carry distinct symptom burdens and require tailored healthcare. An emerging body of literature refutes a conventional assumption that long-term cancer survivors (LTCS), defined as those greater than five years from diagnosis and with cancer in remission, exhibit higher rates of psychiatric diagnoses than cancer-naïve controls (CNC).

Objective: To determine whether differential rates of psychiatric medication use between LTCS and CNC might help to explain the above findings.

Design: A case-control secondary analysis of the National Comorbidity Study-Replication (NCS-R), a probability sample weighted to approximate the 2000 United States census.

Setting: The NCS-R interviews were conducted in subjects' homes.

Participants: The NCS-R is a nationally-representative sample of 5692 community-dwelling Anglophones, 18-years or older. The LTCS were defined as individuals >5 years from diagnosis, with cancer in remission (n=225); CNC as individuals without cancer history (n=3953).

Main Outcome Measure: Odds ratios and 95% confidence intervals were obtained from multivariable logistic regression models evaluating the relationship between cancer status and psychiatric medication use. The interaction between case/control status and psychiatric diagnoses was tested in a logistic regression model to predict psychotropic medication use.

Results: Unadjusted and adjusted differences between groups with regard to psychiatric medication use did not reach significance [OR adjusted for demographic, medical, and psychiatric variables 1.03 95% CI (0.62, 1.70)]. The interaction between case/control status and the carrying of a psychiatric diagnosis was not significantly associated with taking a psychiatric medication [OR adjusted for demographic and medical variables (95% CI): 1.10 (0.42-2.88)].

Conclusion: LTCS and CNC demonstrate comparable rates of psychiatric prescription medication use. The relationship between taking a psychiatric medication and carrying a psychiatric diagnosis is not significantly different between case/control groups. These findings contribute to an emerging hypothesis that LTCS are not a particularly psychiatrically vulnerable group. In an age of healthcare reform, this finding may have policy implications.

Objectives:

  1. Describe the finding of several nationally representative studies on the mental health of long-term cancer survivors.
  2. Access the nationally representative mental health database of the National Comorbidity Study-Replication to begin to answer their own research questions.
  3. Evaluate the need for cancer-specific mental health resources for long-term cancer survivors.

Relevance:
With the number of cancer survivors ballooning to 4% of the U.S. population, understanding the care need of this population grows in importance for psycho-oncologists and general C-L psychiatrists alike.

 

Creating Meaning Following Non-Metastatic Cancer: A Cognitive-Existential Intervention to Improve Existential and Global Quality of Life
Presenting Author:  Pierre Gagnon, MD, FAPM
Co-Authors:  Lise Fillion, François Tardif, Jean-Philippe Cochrane, Michèle Aubin, Anne Dagnault, Marie-Claude Blais, Félix Couture, Harvey Max Chochinov, Louise Provancher, Mélissa Henry

Purpose: People diagnosed with cancer must learn to cope with loss of meaning and empowerment which compromises quality of life. Questions regarding "Why me?", along with universal existential concerns about death, search for meaning, and sense of control over one's life, often constitute a principal, major source of overall suffering. However, very few psychosocial oncology professionals are trained to address existential concerns of cancer patients. Drawing from previous works in psycho-oncology, especially from Dr. William Breitbart, we developed a pragmatic, manually based, 12-session cognitive-existential intervention in both a group and an individual format. We received a grant from the Canadian Cancer Society to assess the efficacy of the intervention to improve existential and global Quality of Life (QoL) of non-metastatic cancer patients through a randomized trial.

Methods: Inclusion criteria were: age 18 and over, history of non-metastatic cancer (past or current), HADS score of <14, no active psychiatric conditions precluding participating in the sessions (psychosis, suicidal risk, etc.). The final cohort consisted of 241 patients with various types of non-metastatic cancer patients, aged from 23 to 83 years-old, who were randomized into the study: 80 in the individual experimental condition, 80 in the group experimental condition, and 81 in the usual care condition. Patients in the usual care condition had access to all the regular clinical, modern psycho-oncology interventions (support groups, cognitive-behavioral interventions, psychopharmacology, etc.). Evaluation of the intervention on the QoL of patients was performed six times from the pre-intervention up to 12 months after the intervention. Existential QoL was measured by the existential subscale of the McGill Quality of Life (MQoL) questionnaire; global Quality of Life was also measured by the MQoL.

Results: To evaluate the efficacy of the intervention on the existential and global quality of life, we performed a mixed modal ANOVA analysis. Results showed that participants in both individual and group conditions had a significant improvement of their existential QoL (M = 0.56, p < .01, and M = 1.10, p < .001 respectively) as well as of their global QoL (M = 0.50, p < .01, and M = 0.94, p < .001 respectively) compared to the usual care condition. Also, over 85% of the participants believed that this intervention should be offered to all cancer patients and 98% believed that participating in the intervention helped them cope with their illness.

Conclusion: Our study confirmed both the acceptability and the efficacy of the intervention. This intervention responds to the strong need for effective, accessible, flexible, and global strategies targeting existential quality of life, an understudied and neglected, yet fundamental, aspect of quality of life.

Objectives:

  1. Describe existential issues confronting cancer patients.
  2. Analyse different approaches to address existential issues in cancer patients.
  3. Apply specific strategies to improve existential distress in cancer patients.

Relevance:
Existential distress represents a major source of deleterious impact on quality of life of cancer patients. A pragmatic, manually based, easily transferable intervention was developed and evaluated to address this issue.

 

Predicting Depression in Patients Initiating Treatment for Head and Neck Cancer
Presenting Author:  William Burke, MD
Co-Authors:  Kendra Schmid, William Lydiatt

Purpose: Depression occurs in up to 40% of patients being treated for cancer of the head and neck (HNC) with significant impact on morbidity and mortality. In addition to known risk factors for depression, such as personal or family history of depression, there are several factors unique to HNC, which make this patient population particularly vulnerable to psychiatric complications. These include aggressive and lengthy treatment strategies, morbid effects from the disease and its treatment, along with high rates of alcohol and tobacco use. Strategies to prevent the occurrence of depression in this population might include prophylactically treating all patients about to undergo treatment for HNC or only those considered to be at high risk to develop depression. Reported risk factors in this population have included age, social support, education, stage and size of tumor, and depression before treatment, although there have been very few prospective analyses.

Methods: A NIMH-funded randomized, double blind, 16 week comparison of escitalopram vs. placebo was conducted in a group of non-depressed subjects diagnosed with HNC who were about to begin cancer treatment. Subjects were stratified by sex, site, stage (early versus advanced), and by primary modality of treatment (radiation versus surgery). The primary outcome measure was the number of participants who developed moderate or greater depression predefined as a score > 11 on the QIDS-SR-16. Potential baseline factors that have previously been reported as associated as risk factors for depression were examined including: age, sex, education, clinical stage, personal or family history of depression/suicide attempts, other psychiatric history, and tumor site.

Results: Of the 148 patients randomized, significantly fewer subjects receiving escitalopram developed depression (10% escitalopram vs. 24.6% placebo, stratified log-rank test p=0.04). Participants at baseline who went on to develop depression had higher baseline symptoms of depression (t= -3.63, P=0.0004). No other baseline measure predicted whether patients became depressed.

Conclusions: Our data supports prior findings that patients with depressive symptoms at the start of HNC treatment are at greater risk of developing depression. However, we found no other baseline factors that might allow targeted prophylactic treatment. New cases of depression can be reduced in this population by the prophylactic use of escitalopram. Since our data do not suggest a profile of patients who could be targeted, all patients should be considered for this intervention.

References:

1. Lydiatt WM, Denman D, McNeilly DP, Pumula SE, Burke WJ. A randomized, placebo-controlled trial of citalopram for the prevention of major depression during treatment for head and neck cancer. Arch Otolaryngol Head Neck Surg 2008; 134(5):528-35.

2. Lydiatt WM, Bessette D, Schmid KK, Sayles H, Burke WJ: Prevention of Depression Using Escitalopram in Patients Undergoing Treatment for Head and Neck Cancer. JAMA Otolaryngology–Head & Neck Surgery, In Press.

Objectives:

  1. Appreciate the risk of depression in patients being treated for cancer of the head and neck.
  2. Consider the potential impact of prophylactic treatment with escitalopram in a group of non-depressed patients with head and neck cancer who are about to initiate treatment of their cancer.
  3. Appreciate that baseline characteristics of the patient, other than depression severity, may not be clinically helpful in developing targeted preventative depression therapy in this setting.

Relevance:
The results of this NIMH-funded trial indicate that prophylactic treatment with escitalopram can reduce the rate of depression in persons initiating treatment for their head and neck cancer.

 

Treating the "Difficult to Treat": Outcomes Among Clients with Severe Mental Illness in a Community-Based Hepatitis C Treatment and Support Program
Presenting Author:  Sanjeev Sockalingam, MD, FRCPC
Co-Authors:  Zoe Dodd, Claire Ann Banga, Kate Mason, Jeff Powis

Background: Despite disproportionately high rates of both mental health issues and substance use amongst people living with HCV (Hepatitis C), patients with this trimorbidity (HCV, mental illness, and substance use issues) are infrequently provided HCV antiviral care. This study sought to examine HCV treatment outcomes for clients with serious mental health issues (SMI) and active polysubstance use who were participating in an inter-professional, community-based model of HCV treatment and supports, including on-site primary care, psychiatric care. and group support.

Methodology: A retrospective chart review of clients who attended at least one group of the Toronto Community Hepatitis C Program (TCHCP) between March 2007 and July 2010 was performed. Patients were classified as having a serious mental illness (SMI) if they had a history of bipolar disorder, psychotic disorder, or past suicide attempt. Information was collected on: demographics, substance use, psychiatric history, and treatment outcomes. Univariate analyses were conducted comparing those with and without SMI.

Results: 129 charts were reviewed, identifying 51 with a SMI. Of these, 62.7% had a history of prior suicide attempt, 31.4% had a history of bipolar disorder, and 15.7% had a psychotic disorder. High rates of active substance use were noted in our sample at program intake, with 31% using crack-cocaine, 34% using alcohol, and 43% using cannabis regularly within the last week. The rate of IDU within the last month was less common (7.8%) in the sample. HCV antiviral therapy was initiated in 9 people with SMI, or 19.6% of those with a detectable HCV viral load (N=46). A relapse or increase in substance use for this group was common (77.8%), as was the requirement for adjusted or new psychotropic medications (66.7%). Despite these and other barriers, adherence to treatment was high and only two patients with SMI (22.2%) missed at least one IFNα dose during the course of treatment. The maximum number of missed doses was two. Sustained virological response in patients with HCV genotype 1 and genotype 2/3 was 66.7% and 100%, respectively, which is comparable to mainstream clinical trials.

Conclusion: Antiviral treatment of HCV in patients with SMI who use substances is feasible in a community-based HCV program with access to primary and specialist psychiatric care, as well as group supports. Further research is required to evaluate factors associated with treatment uptake and outcome among those with SMI.

Objectives:

  1. To understand the relationship between severe mental illness, hepatitis C, and substance use.
  2. To describe the impact of psychiatric illness on hepatitis C treatment outcomes.
  3. To describe factors related to the effective delivery of HCV treatment and support for patients with trimorbidity.

Relevance:
Mental health issues disproportionately impact people with Hepatitis C. Attendees will learn about an effective way to engage and support people living with mental health issues in Hep C treatment.

 

Session F:  Systems-Based Practice
Moderator:  James R. Rundell, MD, FAPM

A Multidisciplinary Curriculum for Mental Health Professionals Working in Primary Care
Presenting Author:  Robert Joseph, MD, FAPM
Co-Authors:  Jessie Fontanella, Hsiang Huang, Kimberly Leary

The integration of mental health care into ambulatory primary care clinics has become a prominent aspect of health care delivery reform. The evidence base supporting this approach has grown tremendously over the past several decades and integration has increasingly been adopted and promoted by payers and policy makers. More recently, integrated mental health has been reinforced by the advent and development of the "medical home" where mental health integration is usually felt to be essential.

Despite the research base supporting integration, the implementation of such models has been slow and has met with mixed success. The reasons for this are myriad and include many structural, administrative, and financial barriers. These include divided leadership between mental health and primary care, insurance carve-outs, mixed payment incentives, confidentiality concerns, and the simple lack of space to accommodate mental health staff in many clinics. As various organizations have overcome these barriers, we have begun to recognize there is a lack of adequately trained mental health providers. It has become clear that mental health work in integrated services is significantly different than traditional mental health delivery and that little/no attention is paid to this work in most training programs (regardless of the discipline).

In response to the need for "work force development," we will present a multidisciplinary curriculum that we have designed to be used for both staff development and training programs. The curriculum is designed in a series of "modules" which focus on the essential elements of which any clinician should know to be effective in primary care settings. These include: background and rationale for integrated care; the "cultural" differences between traditional primary and mental health care; the skill sets necessary to function effectively in primary care; and the role of mental health clinician in primary care. The modules are designed to be flexible and adaptable to different organizational needs. Ideally such a curriculum would be jointly taught with primary care colleagues. The next goal will be to work with our primary care colleagues and to develop training modules that will be appropriate for their staff and trainees.

Objectives:

  1. Be able to identify core components necessary to integrate mental health into primary care delivery.
  2. Learn innovative approaches to appreciating the “cultures” of primary care and the mental health disciplines, and how to successfully meet the challenge of inter-cultural collaboration.
  3. Be able to determine the priority areas for primary care-behavioral health integration and how to leverage system resources to implement a shared curriculum.

Relevance:
Despite the growing stature of integrated care, little attention has been paid to training in this area. This presentation will offer a training curriculum.

 

Assessing the Quality of Inpatient Psychiatry Consultation-Liaison Services: A Review and Recommendation for Next Steps
Presenting Author:  Alexander Thompson, MD, MBA, MPH
Co-Author:  Amelia Dubovsky

Purpose: There are not uniformly agreed-upon quality measures assessing the clinical value and cost-effectiveness of inpatient psychiatric consultation-liaison (C-L) services. This is troublesome given that determining the quality of all aspects of medical practice is an essential element of health care reform. According to the Center for Medicare and Medicaid Services (CMS), tasked with implementing the Affordable Care Act, “quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care” (www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/). Using this nationally accepted framework, we review inpatient C-L psychiatry quality assessment measures across the domains of process, outcome, patient perception, and systems of care. We use this review to recommend critical quality measures and next steps for the consistent use of quality measures in inpatient C-L psychiatry.

Methods: We performed a systematic literature review of quality measures on inpatient psychiatry C-L services. We categorized the results according to the framework derived from CMS criteria to determine whether a framework for quality assessment exists that is consistent with guidelines that will be used by regulatory agencies.

Results: We found few studies related to the effectiveness or quality of inpatient psychiatric C-L services. Areas that have been investigated include the effect psychiatry consultation may have on length of hospital stay, the time it took between a consultation request and when the patient was seen, and the effect psychiatric consultation had on hospital readmission. In each case, the benefit of the C-L services was modest, at best. There have been alternative models of psychiatric consultation proposed, such as “proactive” models where all admissions are screened and seen rather than waiting for a call. There is more robust evidence around the benefit of effective delirium recognition and management in the general hospital. There are clear process, outcome, and organizational measures supporting delirium as a condition on which to focus quality improvement efforts. There is not substantial evidence, however, detailing the role of an inpatient C-L psychiatry service in the treatment of delirium.

Conclusions: To maintain relevance and be seen as a valuable part of hospital medical care, psychiatry C-L services must be more systematic about quality measurement. There is no clear evidence that having a psychiatric C-L service measure things such as “time to consult” or screen all hospital admissions for some psychiatric disorder results in meaningful outcomes important to the health of hospitalized patients. Delirium, on the other hand, is a condition where systematic measurement of a psychiatry C-L service could reveal improvement in outcomes.

Objectives:

  1. Discuss the current published evidence about quality measures for inpatient consultation liaison psychiatry work.
  2. Describe an approach for addressing inpatient C-L psychiatry quality assessment based on the CMS quality measure framework.
  3. Detail quality measures we should be addressing on C-L services and ways of systematically improving the work we are doing.

Relevance:
The audience is or has been involved in consultation psychiatry. It is relevant to discuss the lack of systematic quality measures guiding this important work and ways to improve.

 

C-L Psychiatry as a Teaching Platform for Behavioral Medicine for Advanced Practice Nurses (APNs) and Physician Assistants (PAs): A Pilot Program
Presenting Author:  Leo Pozuelo, MD, FACP, FAPM
Co-Authors:  Debra Kangisser, Elias Khawam, Margo Funk, Adele Viguera, Lilian Gonsalves, Kathy Coffman

Background: With the increasing immersion of health care in the collaborative care model, training of designated care coordinators in behavioral medicine is an increasing topic of interest. Current options are online courses and off-site training seminars. There is a paucity of formal clinical training programs that can provide live experience for care coordinators, who are often APNs and PAs. In addition, we currently lack formal residencies or fellowships for APNs/PAs to pursue postgraduate discipline training.

Methods: At the Cleveland Clinic, 16 APNs/PAs from cardiology and neurology inpatient services were freed from their home clinical services for a two week clinical immersion rotation on the Consultation-Liaison (C-L) Service. The rotation consisted of exposure to inpatient C-L as well as co-located psychosomatic medicine clinics in cardiology and neurology. In addition to one-on-one teaching and rounds with the C-L attending physician, educational resources on behavioral medicine were also provided. Finally, pre- and post-rotation assessments were collected using a Likert scale questionnaire and comment section.

Results: In the 2 week immersion program on the C-L service, the cardiology APNs/PAs demonstrated a collective 83%, 61%, and 84% improvement in depression/anxiety, delirium, and coping with medical illness knowledge. The neurology APNs/PAs registered a 51%, 72%, and 42% improvement in these respective areas as well. Although the rotating clinicians were working only in "shadow capacity" on the C-L service, the general consensus was that the immersion program was a rewarding educational experience. These same clinicians felt more comfortable "curb siding" C-L psychiatry when they returned to their home clinical services.

Conclusions: An immersion program on the C-L service for non-psychiatric APNs/PAs can be a useful medium for exposure to behavioral medicine. These pilot programs can serve as future development of more in-depth and longer-duration psychosomatic medicine modules for APNs/PAs, enhancing their clinical scope of practice in the era of collaborative care. The APM is uniquely situated to provide curriculum guidance. Formal fellowship training in psychosomatic medicine for APNs/PAs should be explored.

Objectives:

  1. Develop a basic understanding of the training and practice scope of APNs/PAs.
  2. Understand how multidisciplinary, inpatient and outpatient learning environments can prepare clinicians to more effectively address the psychosomatic needs of patients.
  3. Formulate an educational behavioral medicine foundation for collaborative relationships between C-L psychiatrists and non-psychiatric APNs/PAs.

Relevance:
Healthcare reform relies on collaborative care, yet APNs/PAs lack specialty training in behavioral medicine. C-L psychiatry can serve as a valuable training platform for these clinicians.

 

Organization of a Multidisciplinary Proactive Consultation Service
Presenting Author:  Paul Desan, MD, PhD, FAPM
Co-Authors:  Paula Zimbrean, Hochang Lee, William Sledge

Purpose: We previously reported that an "embedded" proactive approach to psychiatric consultation in the general medical hospital could reduce length of stay (LOS) in a small-scale project (Desan, et al, Psychosomatics 2011; 52:513-20). This model of screening involved a consultation psychiatrist meeting on a daily basis with medical teams. We estimated that 20-22% of admissions required screening and possible consultation to avoid a potential delay of discharge. In the present project we studied the incidence of behavioral factors potentially affecting discharge in a large-scale project using a different model involving screening with a nurse-social worker-consultant psychiatrist team.

Methods: A Behavioral Intervention Team, consisting of a nurse with extensive behavioral health experience, a social worker, and a consultant psychiatrist, were present on three general medical units at Yale New Haven Hospital during the study period (August 2009 to June 2010). Medical teams and nursing staff identified patients requiring behavioral health screening to the team.

Results: During the study period there were 5641 admissions to these units. An initial screening consultation was performed in 945 (17%), and a plan for necessary services was made with medical teams, floor nursing, social work and discharge care coordination, with additional psychiatric consultation if needed. Follow up services from the Behavioral Intervention Team were required in 416 cases (7%). Issues which were judged to require behavioral health involvement in these 416 cases were psychiatric diagnosis impeding medical care or discharge, 63% of cases, appropriate disposition arrangements, 52% of cases, addiction care, 34% of cases, delirium/dementia care, 18% of cases, and behavior interfering with medical care, 17% of cases. The initial screening process involved 240 team hours and follow-up services required 1107 team hours, for a total of 1307 hours. This represents 0.648 full time equivalents (FTE): 0.184 FTE nursing, 0.164 FTE social work, and 0.300 FTE physician. We have reported elsewhere the beneficial effects of this intervention on LOS, sitter use, and insurance denied days.

Conclusions: These observations confirm in a large-scale study the observations of Desan et al, 2011, that close to 20% of admissions to general medical units require screening for behavioral factors capable of impeding medical care and delaying discharge. Screening and follow-up intervention for such issues can be accomplished with a multidisciplinary team with relatively modest resources, about 0.115 FTE per 1,000 admissions. These observations provide quantitative data for the design of effective proactive consultation services.

Objectives:

  1. To understand the types of behavioral health issues which may impair medical care and impede discharge on general medical inpatient units.
  2. To understand a new multidisciplianary model of consult organization involving early screening and intervention.
  3. To understand workload and resource needs in this new model of efficient consult service delivery.

Relevance:
Future consult services will need to offer integrated and cost effective care, and multidisciplinary teams may offer important advantages in efficiency.

 

The Development of a Competency-Based Assessment Rubric to Measure Psychosomatic Medicine Fellow Milestones
Presenting Author:  Carrie Ernst, MD
Co-Authors:  Catherine Daniels-Brady, Kimberly Klipstein

Purpose: The Accreditation Council for Graduate Medical Education (ACGME) requires residency and fellowship programs to "provide objective assessments" of trainee competence in six core areas: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. While this includes the requirement to "document progressive resident performance improvement appropriate to educational level," each training program has been allowed to select its own assessment tools. Recently, the ACGME has introduced the Next Accreditation System (NAS), which is scheduled to be phased into various residency training programs starting this year. In the NAS, outcomes are measured by the achievement of educational milestones; at this time, no milestones for graduate medical education in psychosomatic medicine have been released by the ACGME.

Methods: In anticipation of this move to competency-based education, we surveyed psychosomatic medicine fellowship directors regarding the use of assessment tools in their programs and conducted a literature review of innovative competency-based assessment tools used by postgraduate training programs. We utilized this information to develop a competency-based assessment rubric that provides an explicitly stated set of performance expectations and demonstrates increasing skill acquisition among medical students, psychiatry residents, and psychosomatic medicine fellows during rotation on the consultation psychiatry service.

Results: Program directors report that multiple assessment tools are utilized, many of which have not been validated or deemed especially useful in linking the core competencies to measurable aspects of clinical performance. Current assessment methods are not generally designed to demonstrate progression in skill acquisition over time, nor are they consistently effective in guiding further improvements in the development of individual trainees. Our rubric utilizes the Dreyfus model for skill acquisition (novice-advanced beginner-competent-proficient-expert), which has been recommended by the ACGME as a tool to demonstrate progression in skill acquisition over time. It is designed to be used primarily by teaching faculty to assess trainees at different points in the rotation. Our experience piloting this instrument on the consultation liaison psychiatry service at Mount Sinai Medical Center will be discussed.

Conclusions: Current assessment methods used by psychosomatic medicine fellowship programs are not reliable or consistent, they do not demonstrate progression in core competency skill acquisition over time, and they do not help individual trainees to make improvements. A competency-based assessment rubric such as the one presented addresses limitations of current assessment methods and is consistent with the stated goals and objectives of ACGME's Next Accreditation System.

References:

1. Dreyfus SE, Dreyfus HL. A Five-Stage Model of the Mental Activities involved in Directed Skill Acquisition, University of California: Berkeley, Operations Research Center, 1980

2. Boateng, BA et al. The Development of a Competency-Based Assessment Rubric to Measure Resident Milestones. J Grad Med Educ 2009 September; 1(1):n45-48

Objectives:

  1. Identify and discuss limitations of current trainee performance assessment tools utilized by psychosomatic medicine fellowship programs.
  2. Review expectations of ACGME’s Next Accreditation System and their potential relevance to psychosomatic medicine training programs.
  3. Develop and pilot a competency-based assessment rubric that provides an explicitly stated set of performance expectations and demonstrates increasing skill acquisition among trainees during rotation on the consultation psychiatry service.

Relevance:
This presentation will familiarize attendees with information about currently utilized methodologies for assessment of psychosomatic medicine trainee performance as well as introduce attendees to a new competency-based assessment rubric.

 

The Impact of Serious Mental Illness on the Risk of Rehospitalization Among Patients with Diabetes
Presenting Author:  Lydia Chwastiak, MD, MPH
Co-Authors:  Dimitry Davydow, Christine McKibbin, Ellen Schur, Mason Burley, Michael McDonell, John Roll, Kenn Daratha

Purpose: Medical rehospitalizations within a month after discharge among patients with diabetes result in tremendous costs to the U.S. healthcare system. Among patients with diabetes, those with comorbid serious mental illness (SMI), such as bipolar disorder and schizophrenia, have higher rates of diabetes complications [1], more diabetes-related hospitalizations [2,3], and increased diabetes-specific mortality [1,2]. The current study examined whether a comorbid SMI diagnosis (bipolar disorder, schizophrenia, or other psychotic disorders) among patients with diabetes is independently associated with medical-surgical rehospitalization within a month of discharge after an initial hospitalization.

Methods: This observational cohort study was comprised of 82,060 adults (≥ 18 years of age) in Washington state who had a medical-surgical hospitalization between 2010 and 2011 with any discharge diagnosis indicating diabetes mellitus (ICD9-CM diagnosis 250). Data on medical-surgical hospitalizations were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Comorbid SMI diagnoses were identified based on ICD-9 CM diagnosis codes indicating bipolar disorder, schizophrenia, or other psychotic disorders. Logistic regression analyses identified factors independently associated with rehospitalization within a month of discharge. Cox Proportional Hazard analyses estimated time to rehospitalization for the entire study period (up to 24 months of follow-up).

Results: Patients with a comorbid SMI diagnosis (n=1, 820) were younger than those without comorbid SMI (n=79,087), and were more likely to have a substance use disorder and to be admitted through the ER for their index hospitalization. After adjusting for demographics, medical comorbidity, and characteristics of the index hospitalization, comorbid SMI diagnosis was independently associated with increased odds of rehospitalization within one month of discharge from the index medical-surgical hospitalization (Odds Ratio: 1.24, 95% Confidence Interval: 1.07, 1.44). Among patients with diabetes and comorbid SMI diagnoses, the most common primary diagnosis for both index hospitalization and rehospitalization within a month of discharge was diabetes itself. The increased risk of rehospitalization persisted throughout the study period of up to 24 months of follow-up (HR: 1.14, 95%CI: 1.05, 1.23).

Conclusions: A comorbid SMI diagnosis in patients with diabetes was independently associated with greater odds of early medical-surgical re-hospitalization. Improving the coordination or integration of outpatient medical and psychiatric care for these complex patients may decrease risk of early rehospitalizations.

References:

1. Mai Q, Holman CD, Sanfilippo FM, Emery JD, Preen DB. Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 2011; 9:118.

2. Becker T, Hux J. Risk of acute complications of diabetes among people with schizophrenia in Ontario, Canada. Diabetes Care 2011; 34(2):398-402.

3. Druss BG, Zhao L, Cummings JR, Shim RS, Rust GS, Marcus SC. Mental comorbidity and quality of diabetes care under medicaid: A 50-state analysis. Med Care 2012; 50(5):428-33.

Objectives:

  1. Understand the impact of serious mental illness on increasing the risk of medical rehospitalization among patients with diabetes.
  2. Identify subgroups of patients with serious mental illness who may be at increased risk for poor medical hospitalization-related outcomes.
  3. Consider patient-level and system-level factors that might contirbute to an increased risk of medical rehospitalization among patients with comorbid diabetes and serious mental illness.

Relevance:
Diabetes imposes a tremendous economic burden on the U.S. healthcare system. Patients with serious mental illness are a health disparities population with respect to diabetes care and outcomes.

 

Session G:  Transplant
Moderator:  Sheila Jowsey, MD, FAPM

A Matched Comparison Study of Medical and Psychiatric Complications in Methadone-Maintained Liver Transplant Recipients: Re-evaluation Nine Years Later
Presenting Author:  Robert Weinrieb, MD
Co-Authors:  Omair Abbasi, Marlee Madora, Alexandra Leto, Kevin Lynch, George Makar

Approximately 85%-90% of opioid-dependent patients receiving methadone maintenance therapy (MMT) in the United States are HCV infected. Although HCV is the most common indication for liver transplantation in the United States, opioid-dependent patients receiving MMT are significantly under-represented in most liver transplant programs and only limited information concerning this population has been published. We evaluated 27 pre-and 10 posttransplant MMT patients in our program for medical/psychiatric complications and anesthesia/analgesia requirements and compared outcomes to a matched control group of 19 non-opiate dependent, non-MMT patients. Our preliminary findings, published in 2004 [1], found fewer MMT retained a spot on the transplant waiting list compared to non-MMT, and over 25% of MMT patients were lost to follow-up. Liver disease (mean CPT score) and transplant waiting times were similar between MMT and non-MMT, but MMT required significantly more intraoperative anesthesia and postoperative analgesia. Significantly more MMT had severe recurrent HCV infection compared to non-MMT (60% vs. 21%) and MMT had worse survival than non-MMT (60% vs. 78.9%). Finally, 20% of MMT patients reported posttransplant alcohol or illicit drug use. Because the central limitation of our study was its small sample size, we present here a re-evaluation of our cohort nine years later and employ a retrospective and cross-sectional design and report outcomes from all newly evaluated and the original 27 pre- and 10 posttransplant MMT patients compared to a new matched control cohort and the original matched control group of 19 non-opiate dependent, non-MMT patients on rates of transplant, survival, recurrent disease, relapse to illicit substance use and alcohol, and medical and psychiatric complications. To our knowledge, this will be the controlled study of MMT patients evaluated serially over nearly a decade.

Objectives:

  1. Relate how and why liver transplant candidacy for methadone-maintained opiate dependent patients has been limited.
  2. Describe how methadone-maintained, opiate-dependent liver transplant patients differ from non-methadone-maintained, non-opiate-dependent liver transplant patients on measures of medical and psychiatric complications.
  3. Apply knowledge from this paper to the psychiatric and medical management of opiate-dependent, methadone-maintained liver transplant patients.

Relevance:
Psychosomatic medicine specialists are likely to be consulted by liver transplant programs requesting guidance on the selection and management of methadone-maintained opiate-dependent patients.

 

Does Psychosocial Evaluation of Potential Lung Transplant Candidates Predict Survival after Lung Transplantation?
Presenting Author:  Peter A. Shapiro, MD, FAPM
Co-Authors:  Yael Holoshitz, David A. Fedoronko, Eric Peterson, David Lederer

Background: Psychosocial assessment is part of pretransplant evaluation. Some studies have found that psychosocial characteristics are correlated with survival of heart transplant patients. Whether this is also the case for lung transplantation has not been studied.

Methods: We retrospectively examined psychiatric evaluations performed during transplant candidacy assessments for patients over age 18 years old who underwent lung transplantation at New York Presbyterian Hospital-Columbia University Medical Center in the years 2006-2011 (n=286). These evaluations were conducted using a semi-structured interview protocol, and recorded with a structured summary form containing an overall rating of risk for psychosocial management problems following transplantation, rated on a five-point scale from low to high risk. Also rated were individual domains including psychiatric diagnosis, smoking, history of substance use, previous treatment adherence, and understanding of transplant procedure. The clinical database of the lung transplant program provided survival data through March 13, 2013. We used Kaplan-Meier survival curves and Cox proportional hazards survival analyses to examine the effect of psychosocial variables on outcome after transplantation, with the composite outcome of death or retransplantation as the primary outcome, and mortality as a secondary outcome.

Results: Death or retransplantation occurred in 70 cases (24.5%) including 67 deaths (23.4%). Among those who died or underwent re-transplantation, the median time to event was 1081.5 days. Median time to death was 1092 days. About half of all events occurred within the first year after transplantation. No patient rated in the highest risk category and only 9 patients in the moderate-to-high risk category received a lung transplant. The effect of risk group on survival free of retransplantation was not significant in unadjusted analyses (p = 0.77) or in analyses adjusting for age at transplantation, sex, and single vs bilateral transplant (p = 0.77), and there was also no effect on survival. Likewise, none of the individual domains assessed was significantly associated with outcome.

Conclusions: In this cohort of patients who underwent lung transplantation in 2006-2011, psychosocial variables measured at evaluation for transplant candidacy did not predict mortality or the composite outcome of mortality or retransplantation, The inclusion of a very small number of patients with moderate-high or high estimated overall risk for psychosocial management problems in the group of patients who eventually received a transplant may have limited the power to detect an association of estimated risk with outcome. Additional research is needed to establish optimally valid and reliable psychosocial assessments for prediction of outcome in lung transplantation.

Objectives:

  1. To explain the psychosocial components of a lung pretransplant evaluation and how overall risk for transplant is determined.
  2. To describe the strength of the association of psychosocial variables measured before or at the time of transplantation with subsequent medical outcomes.
  3. To identify currently relevant research questions about reliable and valid psychosocial predictors of lung transplant outcome, particularly in psychiatrically vulnerable populations.

Relevance:
Psychiatrists may be requested to evaluate and predict outcome for potential lung transplant candidates. This presentation informs and provides a cautionary note to the psychiatrist about limitations of these evaluations.

 

[T] Inflammatory Cytokines and Their Association with Depression and Related Symptoms in Liver Transplant Recipients
Presenting Author:  Amy Lu, MD Candidate
Co-Authors: Andrea DiMartini, Galen Switzer, Mary Amanda Dew, Francis Lotrich

Study: Depression, a common mental health disorder, has strong and consistent correlations with pro-inflammatory cytokines (IL-6, IL-1, TNF-α). While rates of depression are known to be high for transplant patients, whether similar associations between cytokines and depression exist due to the use of immunosuppressants is unknown. We examined the prevalence of depressive and associated symptoms in liver transplant recipients and examined correlations between symptoms and inflammatory cytokines.

Methods: Liver transplant recipients were recruited in the Starzl Transplant Clinic for a cross-sectional, observational study. Sixty-eight recipients provided blood and completed questionnaires assessing symptoms of depression and anxiety (Hospital Anxiety and Depression Scale), sleep disruption (Pittsburgh Sleep Quality Index), pain (Visual Analog Scale), fatigue (Fatigue Symptom Inventory), and general quality of life (SF-36). Blood samples were processed by ELISA assay for pro-inflammatory cytokines (IL-6, IL1ra, TNF-α), anti-inflammatory cytokine (IL-10) and C-reactive protein (CRP) to assess degree of inflammation.


Results: Depressive mood, as defined by HADS score of ≥8, was seen in 23 (33.8%) patients while anxiety, similarly defined, was seen in 30 (44.1%). Clinically significant fatigue, (FSI fatigue score ≥3), was found in 53 (77.9%) patients. Forty-nine (72.1%) were found to suffer from poor sleep (PSQI >5). Average pain scores on the VAS were 2.761 (SD=3.03). Significant correlations between several psychometric measures and inflammatory cytokines were noted. A positive moderate correlation between pain and IL-6 was seen on VAS 0.291 (p=0.018) and the SF-36 subscore for bodily pain -0.351 (p=0.004)(lower score means higher pain). Bodily pain was also correlated with IL-1ra levels (0.348, p=0.005). Role-physical SF-36 subscore correlated with IL-6 (-0.327, p=0.007) and CRP levels (-0.265, p=0.034). IL-10, an anti-inflammatory cytokine, was correlated with SF-36 mental health subscore (0.283, p=0.025)(higher score is better mental health) and total fatigue disruption (-0.254, p=0.044).

Conclusion: Large percentages experienced depression and anxiety symptoms, fatigue, and poor sleep. Similar to other chronic disease states, higher levels of pro-inflammatory cytokines (IL-6, IL1ra) were associated with pain and lower levels of anti-inflammatory cytokine (IL-10) were associated with poorer mental health and fatigue. However some common patterns of associations between depressive symptoms and pro-inflammatory cytokines were not observed.

Significance: This work is highly unique as it is one of the first to examine associations between affective/physical distress and inflammation in transplantation. While some expected correlations emerged, we hypothesize immunosuppression has altered other typical associations between depressive symptoms and inflammatory cytokines. The insights from this work will lead to further investigations examining how immunosuppression may conceal important linkages between inflammation and depressive symptoms.

Objectives:

  1. Recognize and be able to apply knowledge about the prevalence of depressive, anxious, fatigue, poor sleep and pain symptoms in patients following liver transplantation.
  2. Recognize the common associations between inflammatory cytokines and affective symptoms.
  3. Understand the mechanisms between affective disturbances and cytokines and how immunosuppressant medications may have the potential to alter these common associations.

Relevance:
Consultation psychiatrists commonly care for transplant recipients experiencing depression, anxiety, and sleep disruption. This study adds to our understanding of associations between inflammatory cytokines and psychiatric symtomatology in immunosuppressed

 

Quality Improvement Project to Screen and Treat Psychiatric Comorbidities After Liver Transplant
Presenting Author:  Shehzad Niazi, MD, FRCPC
Co-Authors:  Andrew Keaveney, Adriana Vasquez, Sheila Jowsey, Terry Schneekloth, Teresa Rummans

Purpose: Mayo Clinic Florida (MCF) has completed 2558 Liver Transplants (LTs) with 94% patient surviving at one year. These patients are at increased risk for psychiatric disorders [1]. Psychiatric problems include side effects from immunosuppressant agents prescribed post transplant [2]. Depressive symptoms that occur pre- and posttransplant are strongly associated with increased mortality risk in LT patients [4]. A recent study found increased survival rate in patients who received adequate and early treatment for depression [5]. However, a standardized approach to identifying those who need psychiatric intervention is lacking. Process or Quality Improvement (QI) methods can be used to improve process flow to diagnose and treat those with depression and other post-transplant psychiatric comorbidities.

Methods: A multidisciplinary team used Lean Six Sigma principles and QI tools to redesign posttransplant workflow for delivering high value psychiatric care. We created a database of LT patients since January 2010 to identify baseline demographics, severity of medical and psychiatric illnesses, resource utilization, and outcomes. Using Ishikawa diagram we completed a root cause analysis. We identified key leverage points such as lack of routine screening. In the first phase of this three phase QI project we have implemented routine screening for all of our post transplant patients for depression, anxiety, quality of life, substance use, compliance with medical care utilizing standard rating scales PHQ-9 (Patient Health Questionnaire 9 item scale) and GAD-7 9 (Generalized Anxiety Disorder 7 item scale), tracking compliance with lab appointments for immunosuppressant medications, and the out-of-therapeutic range drug levels. Transplant Psychiatry evaluates all of the identified patients based on screening results.

Results: We collected baseline data on 526 MCF LT patients from January 2010 to March 2013. 65% of the LT patients were males and 35% females from 35 states and international locations. 492 were first time recipients and 34 were retransplants. 28% of patients were ≥65 years. Transplant Psychiatry evaluated 76% of patients either pre- or posttransplant. We collected baseline data about MELD score pretransplant, primary and secondary medical and psychiatric diagnoses, hospital length of stay, and graft survival. A spreadsheet was created, accessible to team members, to identify patients at risk that will be presented.

Conclusions: We propose that process improvement methods can detect psychiatric comorbidity, monitor their course pre- and posttransplant, and lead to appropriate interventions to reduce morbidity and mortaility for those at-risk patients receiving liver transplant.

Objectives:

  1. Learn utility of application of process improvement to address clinical problems.
  2. Be able to apply team-based approach to improve care.
  3. Learn the importance of treating psychiatric comorbidities in liver transplant patients.

Relevance:
Process improvement principles can be used to improve delivery of care. We present such a project in Transplant Psychiatry. Same principles can be used in other areas of psychosomatic medicine.

 

Systematic Review and Meta-Analysis of Psychiatric Distress as a Risk Factor for Morbidity and Mortality in Organ Transplantation
Presenting Author:  Mary Amanda Dew, PhD
Co-Authors:  Larissa Myaskovsky, Joel B. Greenhouse, Annette J. DeVito Dabbs, Galen E. Switzer, Diana Shellmer, Donna Posluszny, Emily M. Rosenberger, Jennifer Steel, Andrea F. DiMartini

Purpose: Mental health and well-being are increasingly recognized as important outcomes during the organ transplantation process. This alone would be sufficient to argue for timely identification and treatment of psychiatric distress in transplant patients. But could such distress have more deadly consequences, increasing morbidity and mortality risks after transplantation? Although mental health has been linked to these outcomes in other patient populations, the literature in transplantation has yielded mixed findings and there has been no systematic analysis of the overall trends in this literature. We thus conducted a systematic review and meta-analysis of the associations of psychiatric distress with transplant-related morbidities and mortality.

Methods: Studies that prospectively examined whether psychiatric distress (clinically significant symptoms or diagnosable disorder) affected risk for transplant-related outcomes were retrieved via searches of electronic databases and published bibliographies. Using standard meta-analytic techniques, we calculated combined effect sizes (hazard ratios, HRs) to examine whether psychiatric distress increased the risk of posttransplant mortality and the risk of morbidities in five areas (graft failure/loss, acute graft rejection, chronic rejection, infection, cancer). We also examined whether effect sizes varied depending on study characteristics (e.g., type of organ transplant population, adult vs. pediatric samples).

Results: 36 independent studies (14 heart, 7 liver, 6 kidney, 6 lung, 1 pancreas, 2 mixed recipient samples) published in 1989-2012 were retrieved. Across the 24 studies examining the psychiatric distress-posttransplant mortality association, the combined effect size was HR=1.49 (95% CI, 1.23, 1.81), i.e., risk of mortality was increased by 49% in patients with psychiatric distress. Studies focused on adults found a greater risk (HR=1.53) than those focused on children (HR=1.19), and studies assessing psychiatric distress posttransplant found it to be more strongly associated with mortality (HR=1.90) than studies assessing psychiatric distress only pretransplant (HR=1.31). Type of distress (e.g., depression vs. anxiety) and type of transplant did not affect the associations observed. The presence of psychiatric distress increased the risk of chronic graft rejection (HR, 2.62, CI, 1.14, 6.03) across the 2 studies of this outcome. Psychiatric morbidity was not reliably associated with graft loss/failure (6 studies), acute rejection (3 studies), cancer (1 study), or infection (1 study).

Conclusions: Psychiatric distress is reliably associated with increased risk of posttransplant mortality. The finding that this effect was stronger when distress was assessed posttransplant as opposed to pretransplant suggests that posttransplant mental health assessments and interventions may be particularly critical for maximizing patient outcomes. Very few studies have considered risk effects of psychiatric distress on transplant-related morbidities. However, the association with increased chronic rejection suggests that potential effects on posttransplant morbidities deserve more widespread attention. Mechanisms explaining the associations of psychiatric distress with posttransplant outcomes also warrant investigation so that interventions might be developed and targeted more effectively.

Objectives:

  1. Understand whether and by how much psychiatric morbidity increases the risk of mortality after organ transplantation.
  2. Understand whether and by how much psychiatric morbidity increases the risk of posttransplant-related morbidities including graft loss/failure, acute and chronic graft rejection, cancer, and infection.
  3. Understand factors that moderate the associations of psychiatric morbidity with posttransplant morbidity and mortality, and implications for clinical care.

Relevance:
Consultation-liaison professionals evaluate/treat psychiatric morbidity in transplantation. Our findings indicate the importance of timely mental health care and could be used by C-L professionals to further educate transplant teams.

 

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A Prospective Study of Medical & Psychosocial Outcomes of Solid Organ Transplant Recipients
Presenting Author:  Jose Maldonado, MD, FAPM
Co-Authors:  Yelizaveta Sher, Sermsak Lolak, Heavenly Swendsen, Danica Skibola, Evonne David, Kimberly Standridge, Catherine Sullivan

Background: Available data suggest that in addition to established medical listing criteria, psychosocial and behavioral issues may significantly contribute to posttransplant outcomes. To improve the pretransplant psychosocial evaluation process, we developed a new assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT); which demonstrated excellent inter-rater reliability (Pearson's correlation coefficient = 0.853), and high predictability of posttransplant psychosocial outcomes (P < 0.001) in the original study.

Methods: We conducted a systematized review of our transplant-patient dedicated database and our institution’s electronic medical records to identify every patient who received solid-organ transplants during the period of 6/1/2008 through 7/31/2011 at Stanford University Medical Center. All patients had been assessed with the SIPAT pretransplantation and were closely followed by our transplant multidisciplinary team posttransplantation. We then reviewed and compared prospectively accumulated psychosocial and medical outcomes at the one year of follow-up. The primary outcome was organ failure and mortality; secondary outcomes included occurrence and number of rejection episodes, occurrence and number of medical rehospitalizations, occurrence and number of infection rates, new psychiatric complications or decompensation of pre-existing psychiatric diagnosis, new or recurrent substance abuse, presence of non-adherence, and failure of support system.

Results: Two hundred and seventeen (n=217) subjects were identified and included in the analysis. The average SIPAT score was 12.9 (SD 8.65) with range of 0–42. The average age at the time of transplantation was 51.9 (SD 13.4) years with the range of 20–80 years of age. Although there was no significant difference in the primary outcome (i.e., organ failure, mortality), due to low occurrence, the data clearly demonstrated that a higher SIPAT score was significantly correlated with the probability of poor medical and psychosocial outcomes. The SIPAT scores predicted various posttransplant medical complications, such as organ rejection episodes (p=.02), medical hospitalizations (e.g., transplant related complications) (p<.0001), and infection rates (p=.02). Similarly, SIPAT scores also predicted the occurrence of various posttransplant psychosocial complications, such as psychiatric decompensation (p<.005), presence of non-adherence (p=.09), and failure of support system (p=0.02). When all psychosocial and medical outcomes were combined and logistic regression analysis was performed on these two pooled outcomes, it was also found that higher SIPAT scores increase the probability of an occurrence of undesirable medical outcomes (p=0.04) and negative psychosocial outcomes (p=0.03).

Conclusions: SIPAT is a comprehensive screening tool designed to assist in the psychosocial assessment of organ transplant candidates, while standardizing the evaluation process and helping identify subjects who are at risk for negative outcomes after transplantation. The outcomes of the current study suggest the SIPAT is a promising pretransplantation assessment tool whose results may help predict not only psychosocial outcomes, but also medical outcomes after the transplantation.

Objectives:

  1. Be able to appreciate the prevalence of psychosocial and behavioral issues among medically ill individuals and the extent to which it affects medical care and outcomes.
  2. Be able to understand the psychometric properties of the new instrument, SIPAT, as a tool for the psychosocial assessment of solid organ transplant candidates.
  3. Be able to understand the usefulness of SIPAT in identifying potential problems and allow for correction and selection of transplant candidates, while predicting posttransplant psychosocial and medical outcomes

Relevance:
The use of objective diagnostic tools, such as the SIPAT may assist transplant teams in standardizing the selection process, while helping predict posttransplant medical and psychosocial outcomes.

 

Session H:  Webb Fellows
Moderator:  Michael C. Sharpe, MD, FAPM

Alcohol Use Disorder Focused Collaborative Care: An MHIP Adventure!
Presenting Author:  Shane M. Coleman, MD

Background: The Mental Health Integration Program (MHIP) is a statewide effort in Washington to introduce mental health services into federally qualified health clinics (FQHCs) using a collaborative care (CC) platform. Since 2008, MHIP has successfully helped provide a full range of mental health services to Medicaid patients; however, primary care providers continue to ask for further assistance in caring for patients with alcohol use disorders (AUDs). MHIP data shows that current substance screening reaches 67% of MHIP patients and of those who screen positive approximately 33% receive any substance treatment. AUDs are the single most prevalent type of substance-related diagnosis within MHIP and make up 70% of those who screen positive for substance use.

Objective: To obtain funding and design a clinical trial to test the feasibility of adapting CC to specifically target and treat alcohol use disorders in primary care. A secondary aim will be to obtain preliminary efficacy data on AUD-specific CC.

Method: Adapt CC by incorporating universal alcohol screening, training care managers (CMs) in Motivational Interviewing (MI) and screening, brief intervention and referral to treatment (SBIRT), identify defined routes for referral and treatment options including recommendations for medications shown to help patients decrease or stop their drinking. Implement the AUD-specific CC in a one group, pre-test, post-test fashion in multiple rural FQHCs already participating in MHIP.

Progress: A one-year, 25K grant was obtained from the state of Washington’s Life Sciences Discovery Fund as a flow-through grant from Washington State University’s Rural Mental Health and Substance Abuse Treatment Program of Excellence. Two FQHC systems were successfully recruited to join the Collaborative Care for Alcohol Use Disorder Study (CCAUD), CM’s successfully completed study training protocols, recruitment and enrollment in the study has been successfully initiated, and the treatment phase is scheduled to start this fall.

 

Brief Psychodynamic Therapy for Conversion Disorder (B.P.C.D.): A New Treatment Manual
Presenting Author:  Anna L. Dickerman, MD

Description: Conversion Disorder (Functional Neurologic Symptom Disorder) is a complex psychiatric condition seen in up to one-third of patients in neurologic settings.[1] Patients with conversion disorder may be significantly disabled and face a poor prognosis if left untreated. Furthermore, the management of conversion disorder can be protracted and costly to society and health care agencies. Despite these sobering facts, conversion disorder remains a relatively ignored area of research in medicine and psychiatry, and there is a dearth of evidence-based data on effective treatment strategies. Ideally, treatment of conversion disorder should be relatively rapid in order to reduce the likelihood of long-term morbidity, mortality, and overall costs. A brief psychodynamic intervention (3 sessions) can be a practical and efficacious way to treat patients with conversion disorder directly in the medical setting where they initially present.[2] The author will review the historical and scientific rationale for such an approach, including recent neurobiologic evidence from functional neuroimaging studies. The author will present a new standardized treatment manual entitled B.P.C.D. (Brief Psychodynamic therapy for Conversion Disorder), informed by the work of psychoanalyst and consultation-liaison psychiatrist Milton Viederman, M.D. This manual can ultimately be tested in randomized controlled trials for further validation.

Educational Objectives: At the conclusion of this session, the participant should:

  1. Better appreciate the importance of recognizing and treating conversion disorder as quickly and effectively as possible.
  2. Be familiar with the basic psychoanalytic theory of conversion disorder and understand the rationale for using a brief psychodynamic approach to treat conversion disorder in general medical and neurologic settings.
  3. Be aware of specific psychotherapeutic techniques used in brief psychodynamic treatment of conversion disorder.

Statement of Relevance: This presentation directly relates to treatment of an illness commonly encountered by consultation-liaison psychiatrists in neurologic settings. It also pertains to the need for more evidence-based and cost-effective modalities in psychiatric care.

References:
1. Stone J, Warlow C, Sharpe M: The symptom of functional weakness: a controlled study of 107 patients. Brain 2010; 133:1537-1551.
2. Viederman M: Metaphor and meaning in conversion disorder: a brief active therapy. Psychosom Med 1995; 57:403-409.

 

Street Psychiatry as a Consultation-Liaison Psychiatrist
Presenting Author:  Sheryl B. Fleisch, MD

Background: Street medicine programs that provide health care directly to the unsheltered homeless have become increasingly popular since the early 1990s. The street homeless with severe mental illness are particularly difficult to engage, and psychiatric consultation to this population has shown to be effective in connecting persons to higher levels of care by reaching out to individuals in their environment. At the University of North Carolina (UNC), we developed a community psychiatry rotation, the UNC Homeless Support Program, that brings psychiatry residents outside of the hospital and into the streets of Chapel Hill.

Methods: In 2012-2013, two psychiatry fellows from community psychiatry and psychosomatic medicine piloted a longitudinal, one day/week, year-long rotation in street psychiatry by partnering with a local non-profit organization to locate and engage street homeless in Chapel Hill and to rapidly connect persons to intensive case management services. Now, in 2013-2014, the UNC Department of Psychiatry supports a rotation that engages two psychiatry residents in addition to an attending psychiatrist who provides direct and indirect supervision along with a didactic curriculum on homelessness. Residents learn about assertive engagement, advocacy, and community partnerships.

Results: During the first year of piloting our program, we engaged unsheltered homeless with comorbid medical and psychiatric/substance abuse disorders. Once engaged, we offered direct evaluation (psychiatric and basic medical), medication management, and therapy as well as rapid connection to an array of mental health and social services through community partnerships. Successes thus far include providing psychiatric evaluations that have been used to assist with housing and obtaining Social Security benefits, preventing emergency room visits, and connecting a significant number of persons to wrap-around services.

Conclusion: Psychosomatic medicine is dedicated to the advancement of medical science, education, and healthcare for persons with comorbid psychiatric and general medical conditions. Given the large percentage of homeless who are unable to obtain services in traditional clinic and hospital settings, psychiatric consultation services to this population via direct care on the streets may be the most reliable and cost-effective way to treat this disenfranchised population that seeks primary care and psychiatric services primarily in hospital emergency rooms. Furthermore, street psychiatry provides an innovative training and teaching approach to psychosomatic medicine by developing skills that can be applied to other medical situations and specialties.

 

Valproic Acid as an Adjunct Treatment for Hyperactive Delirium: Postulated Mechanisms of Deliriolytic Action and Case Series
Presenting Author:  Yelizaveta Sher, MD
Co-Authors:  Jose R Maldonado, Anne Catherine Miller, Sermsak Lolak

Background: Delirium is the most-often encountered psychiatric diagnosis in the general hospital, with incidence up to 85% in the intensive care unit (ICU) setting and significant effects on morbidity and mortality. Antipsychotics are considered first-line pharmacological treatment, but they are not FDA approved and can have significant limitations, including QTc prolongation leading to abnormal heart rhythms, extrapyramidal side effects, and paradoxical exacerbation of agitation. Valproic acid (VPA) is a potential adjunct or alternative treatment. It has significant effects on neurotransmitter systems (e.g., dopamine, glutamate, gamma-amino butyric acid, and acetylcholine), kynurenine pathway, neuro-inflammation and oxidative stress, all implicated in the pathophysiology of delirium. These effects could be mediated through VPA’s effect on transcription, including inhibition of histone deacytelase (HDAC). Yet, data on the use of this agent in delirium is limited.

Objective: The goal of this presentation is to discuss rationale behind the use of VPA in delirium and to describe a case series of 16 episodes of hyperactive delirium treated with VPA as an adjunct medication.

Methods/Results: We identified 15 patients with 16 episodes of delirium, diagnosed according to DSM-IV criteria and treated with adjunct VPA by consultation-liaison psychiatrist from 8/1/2011 through 8/31/2012. All patients had hyperactive or mixed delirium, according to the Liptzin criteria. Thirteen patients had resolution of their delirium and all patients had their agitation subside with the addition of VPA to their regimen. There were no adverse outcomes directly ascribed to VPA.

Conclusions: VPA has multiple effects implicated in pathophysiology of delirium. When carefully chosen, VPA can be an effective and well-tolerated treatment option. Further studies are needed.
 

Palliative and Supportive Care Needs of Parents with Metastatic Cancer
Presenting Author:  Eliza M. Park, MD
Co-Authors:  Devon K. Check, Deborah K. Mayer, Katherine E. Reeder-Hayes, Allison M. Deal, Justin M. Yopp, Anna R. Brandon, Laura C. Hanson, Donald L. Rosenstein

Purpose: Cancer is the second leading cause of death in the United States for men and women between the ages of 35-54 years and a major reason for childhood parental loss. Existing clinical strategies designed to help parents with earlier stage disease do not adequately address the unique needs of parents facing a life-limiting cancer diagnosis. To date, there are no published reports in the medical literature of psychosocial, supportive or palliative care interventions designed for parents with metastatic cancer who have dependent children. Data from this mixed methods pilot study will be used to develop supportive care interventions specifically for these patients.

Methods: 60 participants (men and women) diagnosed with stage IV solid tumors who also have at least one dependent child are currently being recruited for a study visit that includes an in-depth, semi-structured interview and validated measures of health care quality of life, depression and anxiety, physical symptom burden, parenting concerns and social support. Interviews address psychosocial adaptation to illness, supportive and palliative care needs, and parental concerns. Interviews are analyzed using constant comparative methods to identify themes to describe the sources and nature of distress in these patients. Descriptive statistics of the sample and standardized measures will also be performed and then triangulated with qualitative data.

Results: Preliminary data from qualitative and statistical analyses will be presented at the meeting.

Conclusions: Data from this pilot study will provide the first in-depth description of psychological distress and supportive care needs specific to patients with advanced cancer who are also parents of dependent children.


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